NHD April 2015 issue 103

NHDmag.com

Issue 103 April 2015

Nutritional benefits of yoghurt Carrie Ruxton and Frankie Phillips p25

ISSN 1756-9567 (Online)

Intensive Weight Control Programme . . . p20

Helen Kingett Bariatric Dietitian

Elderly care home nutrition peg feeding: case study faltering growth cancer care nutrition

dieteticJOBS • web watch • new research

Imagine if there were only 99s

Choice is good Offering a variety of oral nutritional supplements is likely to improve compliance and intake.1 That’s why Nutricia offers a wide range of flavours and formats, including Forticreme Complete (125 g pot), a high energy (200 kcal), high protein (11.9 g) dessert-style nutritional supplement.

Forticreme Complete — the little pot packed with a lot of nutrition.

Visit www.nutriciaONS.co.uk/forticreme to request a sample or arrange a visit from your local Nutricia Representative.

Reference 1. Nieuwenhuizen WF et al. Clin Nutr 2010;29:160–169.

Date of preparation: 02/15

Right patient, right product, right outcomes

from the editor The nutrition and hydration awareness week is now coming to a close as I write and it looks as though there have been a huge number of activities undertaken to celebrate this event.

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

On the first day, Monday 16th March, I and many others went to celebrate the life of Professor Pat Judd. Pat sadly died on 5th March 2015. I am sure that many of you may have personally known Pat or had heard of the work that she did for dietetics. She was an inspirational lady, a leader in education and training, involved in research, a writer of many papers and books . . . the list goes on.

Pat had many talents and was a loving, calm and caring person who will be so sadly missed. I am pleased that I knew Pat and had worked with her during our time sitting on Committees and Council at the BDA. This month we offer once again a selection of varied articles, two of which have a care home theme. Adopt a Care Home (AaCH) and Dementia Awareness by Andy Wallace explores the partnerships of schools working with care homes.

There are benefits to both the school children and the elderly and sharing tea and cake helps improve the nutritional intake of the residents! There is also a great initiative in North Bedfordshire which again focuses on elderly care home nutrition using PUFFINS! How can small black and white birds help you may ask; all is revealed by Bernice Chiswell and Carol Ferdinandez.

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

Obesity management is covered

by Helen Kingett who describes an Intensive Weight Control Programme that centres on low energy liquid diets with appropriate behavioural and/or pharmacological support. Helen tells us more about this approach and shares a case study where the patient has an 18.2% weight loss.

Is cheese is suitable in galactosaemia? Pat Portnoi and Anita MacDonald take us through Cheese in Galactosaemia: a practical guide. As dietitians, it is important that we are fully aware of the suitable cheese types, so that we can accurately advise and support our patients with this condition, their families and carers. The dairy theme continues with Nutritional benefits of yoghurt by Carrie Ruxton and Frankie Phillips. It seems that yoghurt is versatile, suitable for all ages as well as being a beneficial addition to therapeutic diets.

Two paediatric themed articles are also on offer in this issue. One is a case study by Emma Coates on PEG feeding a child with Smith-Magenis Syndrome and the other is Faltering growth by Kate Harrod-Wild - or is it weight faltering?

More is revealed if you read on!

Wishing you all a Happy Easter and a varied NHD read.

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 April 2015 - Issue 103

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Contents

25

COVER STORY

Nutritional benefits of yoghurt 6

News

38 Cancer care nutrition

9

Elderly care home nutrition

42 Dementia and nutrition

14 Smith-Magenis Syndrome:

PEG feeding case study 20 Intensive weight control 30 IMD watch: cheese in

galactosaemia 33 Faltering growth

44 EFAD: Athens conference report 47 Web watch 49 dieteticJOBS 50 Events and courses 51 The final helping

Editorial Panel Chris Rudd Dietetic Advisor

Emma Coates Senior Paediatric Dietitian

Neil Donnelly Fellow of the BDA

Bernice Chiswell Bedford Hospital NHS Trust and North Beds Food First Project

Ursula Arens Writer, Nutrition & Dietetics

Carol Ferdinandez Lead Tissue Viability Nurse, South Essex Partnership Trust

Dr Carrie Ruxton Freelance Dietitian

Helen Kingett Band 7 Bariatric Dietitian

Dr Emma Derbyshire Nutritionist, Health Writer

Pat Portnoi Galactosaemia Support Group

Kate Harrod-Wild Specialist Paediatric Dietitian

Dr Mabel Blades Independent Freelance Dietitian and Nutritionist

Dr Anita MacDonald Consultant Dietitian in IMD

Andy Wallace Commissioning Officer for Quality, Sheffield City Council

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NHDmag.com April 2015 - Issue 103

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news

Chocolate not linked to diabetes risk

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

Previous studies have shown that cocoa and chocolate may help to reduce diabetes risk. Now, a new paper has looked into whether chocolate eating is associated with the diagnosis of diabetes.

Researchers examined data relating to the chocolate consumption of 18,235 non diabetic participants from the Physicians Health Study. Participants were questioned annually over a 14-year period to establish their chocolate eating habits and whether they had been diagnosed with Type 2 diabetes.

Study findings showed that younger and healthy weight men who ate chocolate had lower rates of diabetes (p<0.05).

These results indicate that, when eaten as part of a healthy and balanced diet, chocolate-eating is unlikely to cause diabetes. That said, randomised trials are also needed to reconfirm these findings.

For more information see Matsumoto C and Petrone AB et al (2015). The American Journal of Clinical Nutrition, 101(2), pg 362-367.

Families’ perceptions of soft drinks

Sugary drinks are a popular choice amongst school age children, yet have been linked to obesity. Now, some new research that took place in Switzerland has looked at how sugary drinks are perceived by adults and children from a health perspective.

Researchers asked 100 school-age boys, girls and one of their parents to rate 20 different soft drinks from ‘healthy’ to ‘unhealthy’ using a set of descriptors to rank healthiness.

Sugar content, artificial sweeteners, fruit content and caffeine content were found to be the main predictors of parents’ and children’s health perceptions, with parents and children’s perceptions being similar. That said, fruit content was considered to be more important by children, which may affect their health perceptions.

Overall, this work shows that parents and children have similar health perceptions about soft drinks. It also highlights the importance of parents being major role models to their children, as their opinions and knowledge seem to be similarly reflected in children.

For more information see Bucher T and Siegrist M (2015). British Journal of Nutrition, 113(03), pg 526-535.

Latest on pregnancy and weight gain

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

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It is well known that what we eat in pregnancy can affect the health of the baby, but now there is evidence that weight gain in pregnancy also has its own implications.

The Colorado pre-birth cohort study consisted of 826 women who delivered babies at or after 37 weeks of pregnancy.

Maternal weight gain was measured in early, mid and late pregnancy and the fat composition of newborns was measured within three days of birth.

Study findings showed that a 1.0kg/m2 increase in pregnancy body

NHDmag.com April 2015 - Issue 103

mass index was associated with increased neonatal fat mass, fat-free mass and percentage of body fat. Equally, each 0.1-kg/wk increase in predicted GWG was associated with increases in these parameters.

Overall, authors concluded that maternal weight gain during pregnancy seems to be directly related to the body fat composition of newborns.

For more information see Starling AP and Brinton JT et al (2015). The American Journal of Clinical Nutrition, 101(2), pg 302-309.

news

Latest on dairy and health

When brain tissue undergoes oxidative stress as part of aging, levels of the antioxidant glutathione can be reduced. It is thought that dairy foods may have a role to play in glutathione production.

New observational research has now measured brain glutathione concentrations in 60 older (mean age 68.7 years) healthy subjects along with dairy intakes, using seven-day food records.

Results showed that milk, cheese and calcium intakes were associated with significantly higher brain glutathione levels, with the number of milk servings being associated with higher levels in three brain regions (p≤0.013).

Overall, dairy consumption could help to offset cognition ageing, by providing substrates needed for glutathione synthesis in the brain. More work, ideally RCTs, is needed to test this further.

A second study has also looked into how fatty acids found in dairy products could affect markers of heart and vascular health.

A crossover intervention study using 124 healthy volunteers receiving three servings of dairy or energy-equivalent control daily for four weeks each, separated by a four-week washout period, found that certain plasma fatty acid levels, i.e. pentadecanoic and heptadecanoic acid, were higher after dairy consumption.

While more remains to be known about the role of these fatty acids in health, these findings highlight that regular dairy consumption can alter plasma fatty acid profile within four weeks.

For more information see Choi IY & Lee P et al (2015). The American Journal of Clinical Nutrition, 101(2), pg287-293 and Abdullah MMH & Cyr A et al (2015). British Journal of Nutrition, 113(03), pg 435-444.

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Elderly care home nutrition

The North Bedfordshire ‘PUFFINS’ Project PUFFINS - aren’t they small black and white birds, often pictured with their brightly coloured beaks packed with sand eels? Well, North Bedfordshire is a long way from the coast, but we do have PUFFINS!

Bernice Chiswell Bsc Hons RD Bedford Hospital NHS Trust and North Beds Food First Project

Carol Ferdinandez Msc RN South Essex Partnership Trust, Lead Tissue Viability Nurse

Bernice is a Community Dietitian with over 30 years’ experience. As well as leading part of the North Bedfordshire Food First Project, she has interests in behaviour change, obesity and MS.

Carol has been a Registered Nurse for 22 years, laterally specialising in Tissue Viability with a keen interest in Pressure Ulcer Prevention work.

Our PUFFINS are Pressure Ulcer Food First INitiative Champions, and their ‘habitat’ is the elderly care homes in Bedford and surrounding areas.

The impetus for this project was generated by a desire to see an improvement in the detection and management of malnutrition in care homes for the elderly. At the same time, there are national and local initiatives to stop avoidable pressure ulcers (1). This is seen as a key objective for healthcare providers and commissioners in an effort to ensure provision of high quality, patient-centred care in line with the Department of Health’s ‘Operations Framework for the NHS in England’ 2012/13. Pressure ulcers are seen as an indicator of quality of care and, given that they are largely avoidable, Tissue Viability Nurses (TVNs) have long expressed concern (2). Some are questioning whether pressure ulcers could be construed as an act of nursing negligence (3).

NHS Midlands and East (previously the regional SHA cluster, compromising NHS East Midlands, NHS West Midlands and NHS East of England) set the goal to eliminate avoidable grade 2, 3 and 4 pressure ulcers by December 2012. BAPEN are involved in this ongoing work, looking at disseminating good practice and sharing the resources produced to support this goal (4).

Managing nutrition and hydration is a key aspect of pressure ulcer prevention (5). In view of this, we teamed up with the lead tissue viability nurse in Bedfordshire (South Essex Partnership Trust) who was also considering a champions programme in order to recruit, train and support champions who would be skilled

to focus on both agendas. Studies indicate that provision of champions in addition to effective prevention practices leads to an improvement in patient outcomes with respect to pressure ulcers (6). This multidisciplinary approach of sharing knowledge and expertise enhanced engagement with the care homes. Together I believe we have achieved far more than we could have as separate teams, to promote evidence-based practice in the care homes.

The name PUFFINS came from the champions themselves, as did the title ‘Puffin Flyer’. (I wish we possessed such creative thinking!)

To qualify as a champion, the member of staff needs to be in a position to influence practices in their care home. It was necessary to have the care home management buy in to ensure commitment to change within their care homes, as it is known that practice is linked not only to knowledge, but to inherent beliefs and values (3) 3. We have chefs, senior carers, nurses and home managers who are PUFFINS. In all, 96 have been trained, with a further training course planned in March where a further 22 are booked (with a waiting list).

Once recruited, budding champions attend a one-day training course. This is presented in an interactive way to keep staff engaged and includes topics such as: the aetiology of pressure damage; the cost in terms of morbidity and mortality as well as financial; how to screen using Waterlow and action plans to prevent and managed pressure ulcers. The Food First approach is explained, together with MUST screening and nutrition NHDmag.com April 2015 - Issue 103

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Elderly care home nutrition action plans. Change planning is included to allow the PUFFINS to apply the information to their care home setting and develop a detailed action plan for a realistic change they want to implement.

A pressure ulcer has been described as ‘localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear’ (EPUAP, 2014) (7).

There are graphic slides to increase awareness of the potential severity of pressure ulcers. The fact that 95 percent are preventable, places the onus on staff to screen residents and to take appropriate action to reduce risk. Staff are trained in the fivestep model for pressure ulcer prevention, known as SSKIN (8).

• Surface: make sure your patients have the right support.

• Skin inspection: early inspection means early detection. Show patients & carers what to look for.

• Keep your patients moving.

• Incontinence/moisture: your patients need to be clean and dry.

• Nutrition/hydration: help patients have the right diet and plenty of fluids.

This has been shown to have an impact on prevention and ensure consistency of care (9). Through case studies they practice completing the Waterlow score. Focusing on malnutrition detection and prevention, and again using case studies, the Malnutrition Universal Screening tool is explained and practised (11). As both tools include weight and nutrition, but score in a different way, this can understandably prove confusing for staff. Food fortification is demonstrated, and the staff sample a homemade milk shake. Recipes are provided for high protein, high calorie shakes and desserts.

An educational resource folder is provided for each champion, including guidelines specifically aimed at care homes, presented in an easy-tounderstand format. This includes what should be done, how and when, including the rationale for each intervention.

It is known that education alone rarely makes a difference to practice and Moore (2010) concluded that often work-place challenges of lack of staff and time prevent staff from adhering to evidence based practice (12). Thus, it was important to ensure champions were utilised as drivers of change, acting as a 10

NHDmag.com April 2015 - Issue 103

clinical resource for colleagues. The final exercise of the training day is to support the champions to decide on one realistic change that they would like to implement in their care home, and to produce a detailed change plan to take this forward.

Up to 30 attend at a time. Sponsorship (from wound care companies for example) has enabled refreshments and lunch to be provided.

A questionnaire is completed pre- and posttraining, and this demonstrates an increase in knowledge from attending the day.

The questionnaire includes 10 questions relating to the causes of pressure ulcer, screening for pressure ulcer risk, equipment and procedures for pressure ulcer reduction, MUST screening, nutrition care plans, dehydration, food fortification, etc.

This training has received positive feedback.

Pressure ulcer incidence and effectiveness of the programme

As well as positive evaluation in terms of increased knowledge and enthusiasm, we were keen to see if pressure ulcer incidence was decreased in care homes with PUFFINS. Based on April to December 2014 figures, of elderly care homes with zero to one pressure ulcer alerts, 83 percent had one or more PUFFIN compared to homes with two or more pressure ulcers where only 59 percent had Puffins in place (Total number of homes: 46).

Testimonial from a care home manager

I thought you would appreciate some feedback from the two Puffin sessions we have attended and how it has impacted on the residents’ wellbeing in our care home.

The first session was so informative. It really made us consider if we’re doing enough to promote pressure care and enhanced nutritional support to our vulnerable residents living with dementia in our day-to-day care planning.

We came back and arranged for two cork boards to be erected to display information that we had obtained on the day to cascade information, as well as sharing with the senior staff. We also looked at the pressure relieving equipment to see if it was fit for purpose and whether cushions, for example, fitted correctly into the existing seats so as to not compromise the purpose of the cushion. Soap was replaced with gentle emollients to wash ‘at risk’ skin and has shown to be much kinder and less drying.

Elderly care home nutrition Figure 1

Figure 2

Figure 3

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Elderly care home nutrition We have also had a meeting with our District Nursing Team who are more than willing to provide pressure relieving equipment to any of our Residents with a BMI of 20 or below as a preventative measure. From our point of view, this is a significant cultural shift in that the District Nursing Team are now working with us to be proactive rather than reactive.

Nutritionally, we have tried the recipe suggestions in the Food First information to fortify foods (we were pleased the cooks needed little prompting!) and we think about increasing protein for residents with poor appetite.

We are very grateful for the support you have shown us and look forward to a continued partnership as PUFFIN champions.

PUFFINS FLY-ER

After the training, our fully fledged PUFFINS are eligible to receive their copy of PUFFINs FLY-ER, a two-page monthly publication with sound bites of information presented in a fun way - word searches, anagrams, fast facts, photos, recipes, etc. Topics covered include nutrition and hydration week events, examples of good practice from local care homes, chair based exercises, importance of protein and good dietary sources and assisting residents to eat.

The aim is for staff to look at the flyer in their break times, maybe find a tip to put into practice, but more importantly to keep the importance of good nutrition and pressure ulcer prevention on the agenda for them and their care home.

PUFFIN quarterly meetings

Ongoing support is provided by two-hour quarterly meetings. Topics covered have ranged from meeting the nutritional needs of residents with dementia, managing constipation, textured modified diets and use of soaking solutions for dysphagia, identifying and reducing shear and friction, use of safety cross, case studies using Waterlow and MUST, and discussing appropriate action plans.

The challenges

• Keeping staff engaged when there are many demands on their time.

• Staff changes in the care home.

• Working across two health trusts (Bedford Hospital NHS Trust and South Essex Partnership Trust) with a range of private companies (care 12

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home providers).

• Making time in our busy workloads to continue proactive regular input.

Our next steps

We are conscious of the need to continue auditing the project in order to demonstrate value and to refine it to meet the needs of the staff attending and promote the well-being of the residents. We are currently contacting care home managers and staff who have been trained as PUFFINS to complete a survey monkey questionnaire. This will ask for examples of changes made in response to the training and assess further training needs. We are also in the process of getting badges for the PUFFINS to enhance their recognition in the care homes as champions.

Our top tips for champion projects

• Team up with colleagues for a multidisciplinary approach. Care home staff are busy people, so will not be able to allocate separate champions for different facets of their work.

• Identify allies - the Care Standards and Review team in the social services department have been a great support. (Teams in your area may well have different titles).

• Recruit champions who will be proactive and have a role in their care home which will enable them to influence practice.

• Telephone contact can promote attendance.

Generally our quarterly meetings will receive perhaps five bookings in response to the advertising flyer. A proactive telephone call two weeks ahead of the event will increase attendance to 15 to 20.

• Homes are keen to demonstrate their good practice to CQC, other care homes and perspective residents and their families, so providing the opportunity to demonstrate a proactive approach can gain their engagement.

• Having regular contact both written (providing ongoing information on relevant topics and examples of good practice) and face to face (support group) help to keep champions engaged, motivated and keen to try new ideas.

• Audit of results is essential to measure success and can help secure funding.

For article references please email: info@networkhealthgroup.co.uk

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peg feeding

PEG feeding a child with Smith-Magenis Syndrome: A case study

Emma Coates Senior Paediatric Dietitian Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, North Wales

Since the 1980s, percutaneous endoscopic gastrostomy (PEG) tubes have become an increasingly common way to provide nutrition support in a huge variety of paediatric patient groups (1) (see table 1). The indications for PEG feeding are as wide ranging as the patient groups they are used in (see Table 1) and PEG fed patients are often a significant part of a general paediatric dietitian’s caseload. Many require ongoing support and monitoring throughout the duration of their episode of PEG feeding. This can vary greatly, with many patients requiring dietetic support for many years, perhaps for life. However, there are many patients who can be successfully weaned from PEG feeding to oral diet, which is discussed in this case study.

Jack was transferred to our dietetic department when his family moved to our area at the age of four. He was solely PEG fed at the time of referral. At his previous hospital he had been diagnosed with Smith-Magenis syndrome (SMS), a rare genetic condition caused by a microdeletion or abnormality of

chromosome 17. Patients with SMS may develop distinctive facial features and dental abnormalities are also common.

Mild to moderate cognitive disability, delayed speech and language skills, sleep disturbances and behavioural problems (2) are also common. Further details of SMS features can be found in Table 2, many of which have been observed in Jack’s development and behaviour.

Feeding problems in infancy are common for SMS patients and Jack had been difficult to feed from birth. He did not latch on particularly well when his Mum attempted to breastfeed him.

When bottle feeding was introduced, Jack was slow to feed and he would often cough and splutter during his feeds.

He would easily vomit after each feed and he would cry inconsolably after feeds. Mum described reflux/GORD type symptoms during or post feeds.

His swallowing ability was assessed during a videofluroscopy. He had poor oro-motor control due to low muscle tone and some aspiration was observed with unthickened formula.

Table 1: Examples of PEG fed patient groups and indications for PEG feeding

Emma has been working as a Paediatric Dietitian for five years and her caseload includes HETF, disability, coeliac disease, cystic fibrosis, PKU and childhood obesity.

She has been a local Coeliac UK group organiser for 18 months.

14

Patient groups

Indications for PEG feeding

Neurodisability Cardiology Renal Progressive neuromuscular diseases, e.g.

Duchene’s muscular dystrophy Cystic fibrosis Short bowel syndrome/Malabsorption, e.g.

Crohn’s disease or surgery Oncology Craniofacial abnormalities Allergy Behavioural feeding problems

Unable to achieve and maintain nutritional requirements via oral intake alone leading to faltering growth, this may be due to:

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Physical and cognitive developmental delay Dysphagia or oro-motor difficulties Increased requirements Oral feeding aversion Reflux/GORD Malabsorption Upper GI obstruction/tumours

peg feeding

At the age of three, Jack developed severe vomiting and diarrhoea episodes within the hour following his daytime 150ml bolus feeds of a 1.5kcal/ml tube feed.

However, he was much improved when his formula was thickened with Carobel (Cow and Gate) to stage 1 thickness. This also improved his reflux symptoms. He was referred for placement of a PEG at the age of nine months as his weight had fallen through two centiles, from the 50th to the 9th centile over eight weeks and he had continued to falter despite being prescribed a high calorie formula, 0.9kcal/ml - SMA High Energy, which was the only high calorie formula available at that time. Jack’s mum had attempted to start weaning at six months of age. However, he displayed little interest in solid food and he would only accept lip smears of fruit puree. If mum attempted to place a spoon in his mouth, he would retch and gag, often leading to him vomiting up an entire milk feed. At the age of nine months, Jack’s physical development was delayed and he was only just starting to sit independently. He was also prescribed randitine and domperidone as his reflux symptoms had worsened.

Once the PEG was insitu at almost 11 months of age, Jack’s weight was between the 2nd and 9th centile, his length was following the 2nd centile. He was given 5x150ml gravity bolus feeds of SMA High Energy per day (approximately 86kcal/kg/day). Despite this low calorie intake he gained weight. Mum reported that Jack was not particularly active at this age and this may have accounted for his lowered energy requirements at that time. His weight improved over the next four weeks and he reached the 9th centile. He continued to refuse any oral intake of solids and his oral intake of formula was minimal, despite mum providing the opportunity to take them at each meal and feed during the daytime. At the age of 15 months, Jack’s feed was

swapped to a 1.0kcal/ml tube feed. He continued to tolerate 150ml boluses, but a night-time pump feed had been introduced as his requirements increased. Mum was unable to give the 6x150ml bolus feeds that he needed, due to the development of some challenging behaviours, for example, temper tantrums including kicking and slapping her when she was giving him a bolus feed. To minimise the amount of time Jack was being fed, either via a bolus or his pump, he was swapped on to 1.5kcal/ml feed at the age of 18 months. He also had his PEG tube replaced with a low profile feeding tube - a MicKey button. Jack was frequently awake at night and he would pull the tubing on the feed pump. His parents were sleeping in his room to ensure that they could reset the pump if he pulled the tubing out. He frequently had disrupted pump feeds throughout the night, but parents were unable to feed him anymore than they were doing in the daytime due to his behaviour. Despite this, his weight followed the 9th centile and his length continued along the 2nd centile. He continued to take minimal oral diet and fluids.

At the age of three, Jack developed severe vomiting and diarrhoea episodes within the hour following his daytime 150ml bolus feeds of a 1.5kcal/ml tube feed. However, he seemed to tolerate his night-time feeds, despite the ongoing problems with his behaviour. His reflux seemed worse, despite being prescribed ranitidine and domperidone. He was also later prescribed omeprazole. This eased his reflux symptoms initially, but the episodes of vomiting and diarrhoea persisted. Mum also noted during these episodes that Jack had started to perspire, he seemed to lose concentration and his muscle tone seemed to dip. He would NHDmag.com April 2015 - Issue 103

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peg feeding

At the age of six and a half, Jack’s dietary intake had expanded; he started to include some protein sources such as ham and cheese. He also started to tolerate a larger carbohydrate load and he was managing 20-30g per mealtime. become very drowsy or fall asleep. He was referred to a specialist paediatric gastroenterologist as dumping syndrome was suspected by his paediatrician. For 18 months, Jack was investigated for dumping syndrome via various scans, scopes, blood glucose monitoring and a gastric emptying study. The various test results were not entirely conclusive, but he was given the diagnosis of dumping syndrome. In order to manage his dumping syndrome symptoms, he was placed on a 20-hour pump feed, which ran throughout the day and night and, by doing so, Jack was able to meet his nutrition and hydration requirements. He was able to wear his feed and pump in the daytime by using a specially adapted backpack. This was challenging for his parents and school staff to manage, as Jack would frequently pull the backpack off, or he would need to engage in activities where the backpack was not practical, for example, hydrotherapy.

Jack continued to be solely and continuously PEG fed until he was almost five years old.

Jack then started to eat small amounts of soft plain egg noodles, penne pasta with carbonara sauce and garlic bread. Despite his inexperienced feeding skills, he was able to suck and mulch these foods then swallow them without retching or gagging. He refused to drink any fluids, but he would take custard thick foods made with liquids such as milk or water. A repeat videofluroscopy highlighted that he was safe to swallow these foods and unthickened liquids. All foods were introduced slowly, as it was noted on more than one occasion by mum that if he had more than a handful (his size) of the foods he had started to take, he would start to experience the dumping syndrome 16

NHDmag.com April 2015 - Issue 103

symptoms again. Mum kept a food/symptom diary and the pattern was consistent each time the amount of food taken was increased above the handful sized amount (estimated carbohydrate load of 10-20g). Mum attempted to introduce foods with a lower carbohydrate value; however, Jack refused many of the new foods offered.

At the age of six and a half, Jack’s dietary intake had expanded; he started to include some protein sources such as ham and cheese.

He also started to tolerate a larger carbohydrate load and he was managing 20-30g per mealtime. His intake of fluids also improved and he was drinking approximately 200ml whole cows’ milk at each mealtime (three meals per day). Mum had attempted to give him a variety of 1.5kcal paediatric supplement drinks, but Jack refused to take them.

In light of Jack’s much improved oral intake, we were gradually able to reduce his pump feeds. We monitored his weight each month and he had gained a little more weight than required and he was tracking along the 50th centile. This gave mum the confidence to try more foods with Jack as she understood that he had some reserve weight and it wasn’t as much of a priority to give the highest calorie foods at every meal or snack time. Jack gradually accepted some fruits and vegetables as well as further protein rich foods. His dumping syndrome episodes became far less frequent despite his increasing intake of carbohydrate sources.

At the age of almost nine, Jack was almost PEG-feed free. He was still having a 250ml night-time feed, which was still causing a lot of challenging behaviour. He had started to pull

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.

Date of preparation: 02/15

Still #1 when it comes to choice and flavour range

peg feeding

. . . Jack has developed a number of problems with his PEG site. He has had numerous site infections . . . his entire gastrostomy device (MicKey button) out on a frequent basis, for example, up to 10 to 12 times per day. This would occur during the daytime, despite him not needing daytime feeds any longer. Parents and school staff were able to manage this by receiving training to reinsert his MicKey button. Despite this, Jack continued to frequently pull at his MicKey button, which might have been a sensation he enjoyed rather than it being a painful experience. As a consequence of this behaviour, Jack has developed a number of problems with his PEG site. He has had numerous site infections, which have required antibiotic treatment. Due to his frequent pulling on the device, his site has stretched and can leak gastric contents on the abdominal skin, causing sores, which are an infection risk.

As Jack’s weight and height were satisfactory his night-time feed was discontinued after his 9th birthday. He is now 10 years old and he has continued to eat and drink well on most days. He can be a ‘picky’ eater some days, but his weight and height growth have remained satisfactory. Jack continues to pull at his MicKey button at times, but this behaviour has subsided considerably. He continues to require the tube for medications at present, but it is a future goal for Jack to progress to oral medications.

Jack has been an extremely challenging PEGfed patient to manage due to his physical and behavioural problems. He has required considerable dietetic support, which has taken place over many years at home, at school and within the hospital setting. His case has required wide range of dietetic skills and knowledge, which have eventually facilitated his progression from tube to oral feeding.

Table 2: Common features of Smith-Magenis Syndrome (2)

In infancy

Poor oral feeding Low muscle tone/physical developmental delay Faltering growth Lethargy/extended sleep times Poor development of feeding skills Reflux/GORD Ongoing feeding problems Sleep disturbances - waking during the night, tiredness during the daytime Delayed speech and cognitive development Toileting problems

In childhood

Behavioural problems: ‘Jekyll and Hyde’ type moods, regular temper tantrums, impulsive behaviour, anxiety, easily distracted, aggressive behaviour Self-injurious behaviours including self-hitting, self-biting and skin picking, ‘self-hugging’, hand licking, hand flapping, mouthing objects, insertion of hand in mouth, teeth grinding, body rocking and spinning or twirling objects Physical features - short stature, abnormal curvature of the spine (scoliosis) Sensory abnormalities, e.g. reduced sensitivity to pain and temperature Hoarse voice, possible ear abnormalities that may lead to hearing loss and also possible vision difficulties Some SMS patients may experience cardiac and renal defects

References: 1 El-Matary W. Percutaneous endoscopic gastrostomy in children. Can J Gastroenterol. 2008 Dec; 22(12):993-8 2 What is SMS? (2014). http://smile.smith-magenis.org/ <accessed 09/11/14>

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NHDmag.com April 2015 - Issue 103

Here’s to compliance 30% more people are likely to finish NEW thinner Fortisip Compact1*

to the very last...

Nutricia are delighted to announce the launch of NEW Fortisip Compact now with lower viscosity.2 In a blind comparative test of 100 participants a significantly greater number of people preferred NEW Fortisip Compact compared with Ensure® Compact (p = 0.024).1*

Speak to your local Nutricia Representative to arrange a taste test or to request a sample. *Strawberry flavour. New Fortisip Compact vs Ensure® Compact.

References 1. Data on file, November 2014. Leatherhead Food Research Compact Evaluation Report. A blind comparative test of compact ONS (New Fortisip Compact, Old Fortisip Compact and Ensure® Compact) in 3 flavours (vanilla, strawberry and banana).

2. Data on File, 2014 (excluding chocolate flavour).

Date of preparation: 02/15

Still #1 when it comes to choice and flavour range

obesity management

Intensive Weight Control Programme A dietary approach which has been shown to produce rapid weight loss and, if accompanied by appropriate behavioural and/or pharmacological support, results in successful longer-term weight maintenance, is the use of Low Energy Liquid Diets (LELD) (1).

Helen Kingett Band 7 Bariatric Dietitian, University College London Hospital NHS Trust

Helen has worked in Obesity Management for 10 years and has been working within the Bariatric team as the Lead Dietitian at University College London Hospital for five years.

20

It is not routinely recommended to use Very Low Calorie Diets (VLCD) (800kcal/day or less) to manage obesity (2). LELD differ from Very Low Energy (VLED), Very Low Calorie (VCLD) and Meal Replacement Diets (MR), but are not officially defined. They consist of fully liquid meal replacements providing ≥800 to 1,200kcal per day.

At University College London Hospital NHS Trust (UCLH), an intensive weight control programme (IWCP), including an initial rapid weight loss phase achieved with the use of an LELD, was formulated from research showing that combining intensive dietary intervention with behavioural therapy, or pharmacotherapy can produce greater weight loss and weight loss maintenance than conventional diets (3, 4). Previous similar programmes have shown mean weight loss of 19.7kg + 8.1kg (5) and 14.4kg + 5.7kg (6) at 6 months. A 12-month LELD treatment and maintenance programme completed in primary care showed a mean weight loss of 16.9kg + 6.0kg following the LELD with a documented maintained weight loss at 12-months of ≥15kg in one-third of all patients entering the programme (7).

The IWCP is a medically supervised, intensive weight loss programme that is intended for patients in whom there is a need for either rapid (e.g. for surgery or diabetes control) or substantial weight loss.

It has evolved over a 15-year period and combines an initial liquid meal replacement approach (to maximise initial weight loss), coupled with behavioural dietary counselling and drug therapy, now in the form of Orlistat, to help patients achieve

NHDmag.com April 2015 - Issue 103

weight loss maintenance. The programme has been running for six years at UCLH, introduced to the Trust as a Tier 4 specialist service, by Professor Nick Finer. The programme comprises of three phases. Phase one (eight weeks): a LELD; phase two (eight weeks): dietary transition where the liquid diet is gradually reduced and solid food is re-introduced; phase three (eight weeks): weight maintenance where there is a return to solid food entirely. There is a focus on behaviour change throughout the programme, including goal setting, self-monitoring and support. Education is also provided on nutrition and exercise to support weight management.

Referral criteria

The IWCP is a Tier 4 weight management programme designed for patients with severe or complex obesity in whom initial primary care interventions for weight management have been unsuccessful. Referral criteria includes patients who meet Class II (BMI 35-39.9) or Class III (BMI ≥40) (2) and either EOSS stage 2 (presence of established obesity-related chronic disease, including hypertension, sleep apnoea, reflux disease, Type 2 diabetes, reflux disease, osteoarthritis, polycystic ovary disease) or stage 3 (established end-organ damage, significant obesity-related psychological symptoms, significant functional limitations or significant impairment of well-being) (8). Main referral sources include general practitioners, gynaecologists, GI surgeons and the bariatric surgical team at UCLH who refer patients deemed too high medical risk for surgery.

obesity management Initial assessment

An initial assessment is completed by a specialist physician to evaluate all aspects of the patient’s obesity and medical conditions, including a full endocrine and nutritional blood profile to ensure no contraindications. Patients receive written information about the IWCP and other weight loss approaches and are asked to rate the acceptability of these prior to an appointment for assessment by the Clinical Nurse Specialist (CNS) and Bariatric Dietitian. Dietetic assessment includes patient aspiration, motivation, understanding and expectations of the programme, social history with specific emphasis on how they will cope with the programme, activities of daily living, previous weight loss attempts, including pharmacology, reasons for weight gain, typical day diet history, emotional eating including history of binge eating, night time eating and previous treatment for eating disorders.

Multidisciplinary Team Meeting (MDT)

All patients referred to the IWCP are discussed at an MDT which is attended by the Consultant Physician, Bariatric Dietitian and CNS. Suitability to commence the IWCP is based on patient choice once provided with information regarding the programme, no psychological contraindication such as severe eating disorder and willingness and ability to attend all appointments.

Psychological assessment can be offered to patients in whom there are concerns about concomitant eating or other psychological disorders.

Structure of the programme

The programme runs over a 24-week period, which includes 12 appointments at two-week intervals. It is highly structured, with the content of each visit determined by protocol. Topics covered are informational (e.g. understanding food labels), behavioural (SMART goal setting, diet and exercise diaries) and cognitive (challenging beliefs, managing expectations). Patients are required to sign an agreement committing them to attend all 24 sessions, read all the information provided and bring paperwork back to their clinic appointment. Failure to attend two scheduled appointments will lead to discharge.

Clinics are run by the Bariatric Dietitian and CNS who provide the educational element of the

programme. During each appointment, anthropometry, including weight and body mass index, is completed, along with blood pressure. The topics determined by the protocol are discussed, ‘homework’ from the previous visit is reviewed and information and self- assessment leaflets are given out. ProHealth is used to give information back to patients about their rates of weight loss and distance from goal. While the programme is delivered by the CNS and Bariatric Dietitian, a physician is present and available to give medical advice when needed.

Phase one is delivered by the CNS and includes prescribing a full liquid meal replacement as per the guidelines in Table 1. Patients construct this themselves, which is cost-efficient and free from commercial conflicts. The meal replacement is based on semi-skimmed milk fortified with skimmed milk powder to increase protein content of the diet without unduly increasing the overall volume patients are required to consume. The nutritional composition of the meal replacement diet is approxiNHDmag.com April 2015 - Issue 103

21

obesity management Table 1: Individualised milk prescription based on gender/ BMI and activity levels Low activity level (<2,500 kcal) –

BMI

Medium-high activity level (>2,500 – 3,500 kcal) -

women

men

women

men

35-40

1.5L + 4 heaped tbsp skimmed milk powder

1.5L + 6 heaped tbsp skimmed milk powder

1.5L + 6 heaped tbsp skimmed milk powder

1.75L + 6 heaped tbsp skimmed milk powder

40-50

1.5L + 6 heaped tbsp skimmed milk powder

1.5L + 6 heaped tbsp skimmed milk powder

1.5L + 6 heaped tbsp skimmed milk powder

1.75L + 6 heaped tbsp skimmed milk powder

50+

1.75 L + 6 heaped tbsp skimmed milk powder

1.75 L + 6 heaped tbsp skimmed milk powder

1.75 L + 6 heaped tbsp skimmed milk powder

1.75 L + 6 heaped tbsp skimmed milk powder

mately 1,100kcal plus 90g of protein. Patients are prescribed a once daily A-Z Complete multivitamin, Fybogel, to provide soluble fibre, one salty drink, plus one and a half litres of fluid in addition to the meal replacement. Patients may also have up to five sticks of sugar-free chewing gum, one sachet of sugar-free jelly and sugarfree drinks. Protocol-driven adjustments of concomitant medications include pre-emptive reductions of insulin/oral hypoglycaemics, hypotensives and diuretics. Patients on <100 units insulin daily have their insulin stopped at initiation of the diet, while others have their dose halved. The main side-effects of the diet include constipation and diarrhoea. Patients do not report symptoms seen with severe ketosis induced by VLCDs. Unwanted effects, glycaemic control and blood pressure are closely monitored, particularly through the first phase and, if appropriate, patients are offered alternatives to the meal replacement, such as a lactofree diet and adjustments to their medications.

Patients may be advised to discontinue the programme if they have severe symptoms (e.g. diarrhoea), or for safety reasons if the patient is unable to consume the diet in its totality - usually evidenced by excessive weight loss. Patients are introduced to behaviour change during the first phase and begin to set SMART goals and self-monitoring through the use of food diaries and/or exercise apps. During this phase, the weight loss target is 10 percent.

Phase two is delivered by the Bariatric Dietitian with some input from the CNS. This phase includes a reduction of the meal replacement prescription to half of that prescribed in phase one, plus an introduction of a 200kcal meal and a 400kcal meal from a limited menu of meal and 22

NHDmag.com April 2015 - Issue 103

snack choices. Specific guidance is provided with regards to the food introduction, including types of foods, meal composition, recipes and overcoming challenges associated with re-introduction of solid foods. Pharmacological support in the form of Orlistat is prescribed if appropriate during this phase. Behaviour change including the use of SMART goal setting and self-monitoring continues alongside additional nutritional education, including balance of good health, portion size, food labelling, eating triggers and physical versus head hunger.

Phase three is described as the weight maintenance phase, with focus on behaviour change and education, which includes individual dietetic counselling, time and stress management, meal planning and support for long-term weight maintenance, including recommendations for ongoing support in the patient’s local community. During this phase, the meal replacement is discontinued. A final review, four-weeks after the programme, is conducted by the Specialist Physician.

Audit data

Weight loss targets have been defined by SIGN guidelines as: • In patients with BMI 25 to 35kg/m2, obesity-related comorbidities are less likely to be present and a five to 10 percent weight loss (approximately five to 10kgs) is required for cardiovascular disease and metabolic risk reduction.

• In patients with BMI >35kg/m2 obesityrelated comorbidities are likely to be present, therefore weight loss interventions should be targeted to improving these comorbidities; in many individuals, a greater than 15 to

obesity management Table 2: Summary of weight loss during the intensive weight control programme Phase of intensive weight management programme

Weight (kg)

BMI (kg/m2)

Start of the programme

102.8

39.2

End phase one (visit 5)

91.4

34.8

11

End phase two (visit 9)

85.8

32.7

16.5

End phase three (visit 12)

84.4

32.2

17.8

84

32

18.2

Final review

20 percent weight loss (will always be over 10kg) will be required to obtain a sustained improvement in comorbidity (9).

Recent audit data of IWCP at UCLH shows 55 percent of patients complete the programme with an average weight loss of 13.7kg (11.7%).

The audit identified reasons for non-completion as dislike and/or intolerance of milk, mental health problems, distance to travel, pregnancy and non-compliance with the programme.

Case study A 33-year-old female was referred via her General Practitioner. Her previous medical history included obesity class II stage 2, primary subfertility, polycystic ovary syndrome with high androgen levels, hypercholesterolemia and an acute episode of optic neuritis paraesthesia three years previously. The patient was being considered for in-vitro fertilisation but was required to reduce her weight to BMI 32kg/m2. The patient’s weight started to increase at the age of 15 and reached a maximum of 110kg at the age of 23. She had tried many diets including Lighter Life and the Cambridge diet and had managed to lose weight, but found it difficult to retain

% weight loss

long-term weight loss. The patient attended 11 out of 12 appointments and had a total weight loss of 18.8kg (18.2%). The final review blood tests revealed a normalisation of androgen and sex hormone binding globulin levels.

Strengths and weaknesses of the programme

The programme achieves substantial weight loss, greater than with conventional diets, in patients who may have failed to respond to conventional dietary approaches previously, or have a need for urgent or substantial weight loss. The programme is costly in terms of dietetic and CNS time, but previous iterations with group sessions, or less frequent visits proved less successful. The programme would benefit from more structured exercise and activity content; a pilot of group sessions run through the UCLH cardiac rehabilitation department proved popular and beneficial, but funding for continuing this was not obtained.

Lastly, long-term weight loss maintenance requires continued contact, supervision and support, but the poor provision of Tier 3 (CCGcommissioned community based services) has meant few patients continue their management in the community.

References 1 Finer N, Finer S and Naoumova RP (1992). Drug therapy after very-low-calorie diets. Am J Clin Nutr; 56-195S-8S 2 NICE. Obesity. London: National Institute for Health and Clinical Excellence (2014). www.nice.org.uk/guidance/cg189 3 Waddon TA (1993). Treatment of Obesity by moderate and severe caloric restriction. Results of clinical trials. Ann Inten Med. Oct;119: 688-93 4 Johansson K, Neovius M, Hemmingsson E (2014). Effects of obesity drugs, diet and exercise on weight-loss maintenance after very low calorie diets or low calorie diets: a systemic review and meta-analysis of a randomised control trial. Am J Clin Nutr. 99: 14-235 5 Coculescu R, Valls R, Finer N et al (1994). Three-year experience of an intensive multi-modality obesity treatment programme. [Abstract]. Int J Obes; 18, 839 6 Barret P, Finer N, Fisher C, Boyle G (1999). Evaluation of a multimodality treatment programme for weight management at the Luton and Dunstable Hospital NHS Trust. Journal of Human Nutrition and Dietetics; 12: 43-52 7 Lean M, Brosnahan et al (2013). Feasibility and indicative results from a 12-month low-energy liquid diet treatment and maintenance programme for severe obesity. British Journal of General Practice; February e116 8 Sharma AM, Kushner RF (2009). A proposed clinical staging system for obesity Int J Obes; 33: 289-295 9 SIGN Management of obesity. 115. Edinburgh: Scottish Intercollegiate Guidelines Network; 2010. Available from: www.sign.ac.uk/pdf/sign115.pdf

NHDmag.com April 2015 - Issue 103

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NUTRITIONAL BENEFITS OF YOGHURT Carrie Ruxton and Frankie Phillips p25

ISSN 1756-9567 (Print)

INTENSIVE WEIGHT CONTROL PROGRAMME . . . p20

Bariatric Dietitian, University College London Hospital

ELDERLY CARE HOME NUTRITION PEG FEEDING: CASE STUDY FALTERING GROWTH CANCER CARE NUTRITION

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cover story

Nutritional benefits of yoghurt Yoghurt has been eaten around the world for centuries, but is a relatively recent addition to the UK diet, only appearing as a mainstream dietary component in the 1960s. The most recent Mintel Marketing Report on yoghurt and desserts (UK) reported that 84 percent of households purchased yoghurt in 2013 (1).

Carrie Ruxton PhD, Freelance Dietitian

Frankie Phillips PhD, Freelance Dietitian

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.

www.nutritioncommunications.com

@drcarrieruxton Dr Frankie Phillips is a Registered Dietitian and Nutritionist (Public Health). Her research work has led her into communications, giving evidencebased messages about nutrition to a range of audiences, including health professionals. @drfrankiep

Yoghurt is defined in the Code of Practice vitamin D, or may be enriched with extra (2) as an ‘acidified coagulated milk prod- calcium qualifying them for bone health uct made from milk or any combination claims (3). The fat content of yoghurt of milk and/or products obtained from varies widely, ranging from ‘fat free’ vamilk, in which, after pasteurisation, lactic rieties with less than 0.5% fat, through acid has been produced within the prod- to low-fat yoghurts containing less than uct by the bacterial cultures Lactobacillus three percent fat and up to 10 percent for bulgaricus and/or Streptococcus thermophi- some Greek style types. Table 1 presents lus with which may be used other suitable the macronutrient content of a selection bacteria. The approof yoghurts showYoghurt can provide priate live organisms ing large variations should be viable and in the energy, fat useful amounts of several abundant’. and carbohydrate Yoghurts are contents.

Several yonutrients which may help to now available with ghurt types are ofa range of additional ficially a ‘source’ or ensure that micronutrient ingredients, using ‘high in’ key microvarious production recommendations are met in nutrients, representmethods, leading to ing 15 percent and 30 a vast choice from percent respectively vulnerable groups thick, strained or of the EU RecomGreek style yoghurts mended Daily Allowto flavoured drinkance. For example, ing yoghurts, offering products to suit different age groups all yoghurts are a source of calcium, all except full fat fruit yoghurt are a source of and needs. phosphorus, low fat and thick and creamy NUTRITIONAL PROFILE yoghurts are a source of riboflavin, and all Yoghurt is considered a nutrient-dense yoghurts except thick and creamy are a food, but any added ingredients and source, or high in iodine. production methods will dictate the Yoghurt can provide useful amounts final nutritional content. Being made of several nutrients which may help to from milk, yoghurt is typically a good ensure that micronutrient recommendasource of high-quality protein and con- tions are met in vulnerable groups. The tains a highly bioavailable source of cal- National Diet and Nutrition Survey(4) cium. It can also be a source of iodine, (NDNS) reveals that riboflavin, vitamin phosphorus and potassium, as well as D, calcium, magnesium and potassium are low in the diets of children, adolesriboflavin (B2) and vitamin B12.

Although not naturally a source, cents, women and older adults, with sigsome yoghurt products are fortified with nificant numbers in these groups failing NHDmag.com April 2015 - Issue 103

25

yoghurt Table 1: Nutrient content of yoghurts per 100g

Energy (kcal)

Full fat fruit yoghurt

Low fat fruit yoghurt

Low fat plain yoghurt

Fat free fruit yoghurt

Plain Greek style yoghurt

Fruit Greek style yoghurt

Thick & creamy / twinpot yoghurt

109

78

56

47

133

137

124

Protein (g)

4.0

4.2

4.8

4.8

5.7

4.8

4.8

Carbohydrate (g)

17.7

13.7

7.5

7.0

4.8

11.2

16.2

Total sugars (g)

16.6

12.7

7.5

6.3

4.5

10.5

15.6

Fat (g)

3.0

1.1

1.0

0.2

10.2

8.4

3.7

Saturates (g)

2.0

0.8

0.7

0.1

6.8

5.6

-

Source: McCance and Widdowson’s The Composition of Foods (2002)

to reach lower reference nutrient intakes for these essential nutrients.

Table 2 summarises the contribution that yoghurt and fromage frais make to energy, macronutrient and micronutrient intakes in adults and children, using data extracted from the most recent NDNS (4).

4-18 years n=1687

19-64 years n=1655

Energy

1.4

1.1

Total fat

1.1

0.8

Saturates

1.9

1.3

Carbohydrate

1.5

1.4

Total sugars

3.1

2.9

NMES

3.1

3.0

Protein

1.8

1.5

Vitamin A

1.5

0.8

Interestingly, despite contributing less than two percent to daily energy intakes and modest amounts of fat and sugar, yoghurt provides three to four percent of certain B vitamins, calcium and iodine. A recent review of the contribution of yoghurt to the diets of UK children and adults (3) showed that children up to age three consumed the most yoghurt (mean intakes 43.8g/ day to 46.7g/day), whilst adolescents consumed the least (21g/day). In adults, the highest mean consumption was 35.7g/day in 50 to 64 year olds. Low-fat yoghurt was the most commonly consumed type. This review also reported the findings of a simple modelling analysis which determined whether daily inclusion of a pot of low-fat fruit yoghurt daily could improve adolescents’ nutritional intakes. The results showed that eating 125g of yoghurt daily could potentially increase mean intakes of calcium and iodine above Reference Nutrient Intake, as well as boosting zinc intakes.

Thiamin

1.8

1.9

YOGHURT AND HEALTH

Riboflavin

3.6

3.2

Vitamin B6

2.4

0.3

Vitamin B12

2.9

1.7

Vitamin D

1.9

0.7

Calcium

3.8

4.2

Magnesium

1.6

1.4

Phosphorus

2.7

2.5

Zinc

1.7

1.5

Iodine

4.7

4.7

Table 2: Percentage contribution to nutrient intakes

Key: NMES, non-milk extrinsic sugars

26

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There is a wealth of evidence about the relationship between dairy foods and health. Several studies now show that yoghurt consumption in particular is associated with benefits relating to bone health, cardiovascular health, diabetes and obesity.

Bone health Yoghurt provides many of the nutrients needed for optimal bone health such as calcium, protein, magnesium, zinc and phosphorus. The calcium present in yoghurt is bioavailable as the low pH ionises calcium, facilitating intestinal calcium uptake.

YOGHURT An Italian study (5) suggested that yoghurt was an independent predictor of bone mineral density, whilst data from a prospective cohort study of 3,212 subjects (6) from the Framingham Offspring Study showed that consuming one 125g pot of yoghurt daily was positively associated with bone mineral density. In addition, yoghurt showed a weak but protective trend for hip fracture. Another randomised, double-blind trial (7) found that eating a 125g pot of yoghurt fortified with calcium (800mg) and vitamin D (10µg) led to reduced parathyroid hormone and bone resorption markers.

Cardiovascular Observational studies and meta-analyses have reported beneficial associations between yoghurt intake and cardiovascular disease risk factors. Analyses from the US Framingham cohort found that regular consumers of low-fat yoghurt were 31 percent less likely to develop high blood pressure than those who ate it infrequently. A high yoghurt intake was thought to support blood pressure control and may even help prevent hypertension (8). A meta-analysis (9) of 14 studies showed a clinically significant reduction in blood pressure (3.1 mmHg systolic; 1.09 mmHg diastolic) when yoghurt was consumed regularly with the greatest benefits seen in those with hypertension. The population-based MONA LISA Study in France (10) found that adults who consumed more low-fat dairy products had the lowest risk for cardiovascular mortality and the most favourable lipid profiles. In a recent review, Astrup (11) reported that fermented yoghurt products produced a four percent and five percent decrease in total and LDL-cholesterol respectively, whilst an eight-week randomised controlled trial of overweight adults revealed an 8.4% reduction in LDL-cholesterol after consumption of yoghurt fermented with Enterococcus faecium and Streptococcus thermophilus.

Type 2 diabetes Data from cohort studies (9) and meta-analyses (12, 13, 14) have associated yoghurt consumption with a lower risk of Type 2 diabetes (up to 22 percent), as well as improved insulin resistance, lower circulating levels of glucose and

lower triglycerides. An analysis of the longitudinal EPIC survey (15) found a 28 percent reduced risk of developing Type 2 diabetes when yoghurt was consumed regularly, particularly when it replaced less healthy snacks. The authors suggested that the benefits of yoghurt could be exerted via probiotic bacteria and a special form of vitamin K associated with fermentation.

Yoghurt and weight management Low-fat yoghurt has been a cornerstone of weight management advice for decades. Evidence from large observational studies suggests that yoghurt is one of a group of foods repeatedly associated with healthier weight changes. In a pooled adjusted analysis of dietary habits and weight change in over 120,000 healthy, non-obese US adults, consumption of low-fat yoghurt was associated with a decrease in weight (1.0-2.0kg) over a four-year period a greater effect than that seen for vegetables, fruit and wholegrains (16).

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27

YOGHURT Other epidemiological studies (17), as well as large systematic reviews (18), suggest that there is a modest but significant inverse association between dairy consumption and body weight. In addition, dairy consumption does not seem to contribute to increased risk of weight gain, metabolic syndrome or cardiovascular disease (19, 20, 21, 22). This is further supported by small clinical studies (23, 24) which have found reductions in weight (1.4-1.6kg) associated with eating around three daily servings of fat-free yoghurt. Yoghurt may also have a suppressive effect on appetite (25).

Lactose intolerance Yoghurt naturally contains less lactose than milk (typically 3.4% compared with 6.0%)(26), suggesting that it may be better tolerated than milk in people with lactose intolerance, possibly due to slower gastric emptying and gut transit (27). An opinion by the European Food Safety Authority (28) confirmed that live yoghurt can be included in the diets of people with lactose maldigestion because, within the gut, the cultures in live yoghurt improve the digestion of lactose, breaking it down to lactic acid. This led to an authorised EU health claim of ‘improved lactose digestion’ for yoghurts and fermented milks containing minimum levels of live cultures. Dietitians can now feel confident in giving advice on this to patients with lactose intolerance or those choosing to avoid lactose.

CONCLUSION

Yoghurt is a unique and historic food which provides useful amounts of several key vitamins and minerals, as well as high quality protein. Its versatility makes yoghurt suitable for all ages as well as a beneficial addition to therapeutic diets such as those aimed at improving cardiovascular risk factors, bone health and weight management.

Yoghurt facts and myths • The sugar content in yoghurt varies widely with many products containing no added sugar.

Yoghurt provides only three percent of NME sugars on average in the UK diet.

• Yoghurt is an official source of calcium, phosphorus, iodine and riboflavin.

• Live yoghurt can often be tolerated by people with lactose maldigestion due to the lower lactose level and the gut effects of the yoghurt cultures.

• Regular yoghurt consumption is associated with a lower risk of Type 2 diabetes and cardiovascular disease.

• Yoghurt may help to support bone health and weight management.

Acknowledgement This article was funded by Danone. The content reflects the opinions of the authors.

References 1 Mintel (2013). Yoghurt and desserts: Mintel Marketing Report, July 2013. London: Mintel International 2 Provision Trade Federation (2009). Yoghurt code. Available at: www.provtrade.co.uk/technical-and-legislation/codes-of-practice-and-guidance.aspx 3 Williams EB et al (2015). Nutr Bull 40: 9-32 4 Bates B et al (2014). National Diet and Nutrition Survey: Results from years 1-4 (combined) of the rolling programme (2008/8-2011/12). Public Health England 5 Livecci V (2012). BMC Infect Dis 12: 192 6 Sahni S et al (2013). Arch Osteo 8: 119 7 Bonjour JP et al (2013). J Clin Endocrin Metab 98: 2915-21 8 Wang H et al (2013). Nutr Res 18-26 9 Dong JY et al (2013). Br J Nutr 110: 1188-1194 10 Huo Yung Kai S et al (2013). Eur J Prev Cardiol 21: 1557-67 11 Astrup A (2014). Am J Clin Nutr 99: 1235S-42S 12 Aune D et al (2013). Am J Clin Nutr 98: 1066-83 13 Elwood PC et al (2010). Lipids 45: 925-939 14 Tong X et al (2011). Eur J Clin Nutr 65: 1027-31 15 O’Connor LM et al (2014). Diabetologia 57: 909-17 16 Mozaffarian D et al (2011). N Engl J Med 364: 2392-404 17 Louie JC et al (2011). Obes Rev 12: 582-592 18 Kratz MT et al (2013). Eur J Nutr 52: 1-24 19 Soedamah-Muthu SS et al (2011). Am J Clin Nutr 93: 158-71 20 Huth PJ & Park KM (2012). Adv Nutr 3: 266-85 21 Ralson RA et al (2012). J Hum Hypertens 26: 3-13 22 Lorenzen JK & Astrup A (2011). Br J Nutr 105: 1823-31 23 Zemel MB (2005). J Amer Coll Nutr 24 (6): 537S-46S 24 Jacques PF & Wang H (2014). Am J Clin Nutr 99: 1229S-34S 25 Douglas SM et al (2013). Appetite 60:117-22 26 Gaucheron F (2011). J Am Coll Nutr 30:400S-9S 27 Arrigoni E et al (1994). Am J Clin Nutr 60: 926-9 28 European Food Safety Authority (2010). EFSA Journal 8(10): 1763-80

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imd watch

CHEESE IN GALACTOSAEMIA: A PRACTICAL GUIDE It is now 15 years since some types of mature hard cheese were first allowed for patients with galactosaemia in the UK. Fifteen years ago we found it hard to accept that some types of cheese could be sufficiently low in galactose to be suitable for galactosaemia, but we have made great progress since those early days.

Anita MacDonald Consultant Dietitian in IMD, Birmingham Children’s Hospital

Pat Portnoi, Dietitian, Register Coordinator, Galactosaemia Support Group (GSG)

One of the UK’s top paediatric dietitians, Anita’s specialism lies with inherited metabolic disorders. She spends 50 percent of her professional time in clinical work with children and 50 percent researching and teaching.

Pat worked as a dietitian in the NHS before joining SHS in 1981, becoming a director of the company in 1990.

She is now retired, but continues to work with the galactosaemia support group and with PKU, attending NSPKU conferences.

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In fact, since 2000, the UK Galactosaemia Support Group (GSG) has sponsored the testing of over 173 samples of cheese on 12 different occasions (1, 2).

Even the USA dietitians are following the UK lead (3).

Which criteria are used to decide if a cheese is suitable in galactosaemia?

To ensure a cheese is suitable, at least five samples of a UK or European cheese (with knowledge of origin and processing) are analysed to check its lactose and galactose content. If they have a lactose and galactose content that is consistently below 10mg/100g when analysed, they are permitted in the diet.

This is less than the amount of galactose in 0.5ml cows’ milk which is minimal.

It is difficult to detect lactose/galactose below this amount.

How is lactose and galactose removed in cheese production?

The lactose and galactose in cheese is removed through different processes.

1 Cheese is made by coagulating milk. This transfers milk into a semi-solid mass and separates milk into solid curds (casein) and liquid whey. Most cheese types contain high levels of casein (containing no more than 1.0% lactose), but low levels of whey (which contains 70 percent lactose). Therefore, removing whey by drainage is important in reducing the lactose content of cheese, and during this stage, most of the lactose will be removed (approximately 98 percent).

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2 The temperature of coagulum, starter culture, coagulating enzyme, and the acid produced, influences the properties of the curd and degree of whey expulsion and hence the final lactose content.

3 As the cheese ages or matures it dries out and as it dries out, it loses lactose and galactose in the whey.

CHEESE ALLOWED IN GALACTOSAEMIA

Cheddar cheese Unfortunately, we have had to change the advice we give on cheddar cheese, primarily due to the poor availability of the cheddar cheese that we first analysed. The GSG recommended mature or very mature cheddar cheese from the West Country Farmhouse Cheese makers group, which was consistently very low in lactose/galactose. The number of farms producing this cheese has fallen; it is no longer available to purchase online and very few supermarkets now stock it. To add to the difficulty, it became clear through the work of the GSG that some caregivers/parents were mistakenly using the wrong type of cheddar cheese. Therefore, we have reanalysed new types of mature cheddar cheese.

We now only recommend cheddar cheese by brand name to avoid confusion for both caregivers and dietitians.

Only five types of cheddar cheese are now allowed and are all suitably low in lactose and galactose (Figure 1).

Other hard cheese allowed in galactosaemia are Emmental, Gruyere, Jarlsberg, French Comté, Italian Parmesan and Grana Padano (Figure 2).

imd watch Figure 1: Suitable cheddar cheeses tested and permitted in a low galactose diet in galactosaemia Lye Cross Farm West Country Farmhouse Mature Cheddar

Lye Cross Farm West Country Farmhouse Vintage Cheddar

Lidl - Valley Spire West Country Farmhouse Mature Cheddar

Tesco - West Country Farmhouse Extra Mature Cheddar

Sainsbury’s -Taste the difference West Country Farmhouse Extra Mature Cheddar

Figure 2: Suitable mature cheeses tested and permitted in a low galactose diet in galactosaemia These cheeses are made to very specific recipes in certain areas of a country following old traditions and are suitable in galactosaemia.

Emmental is a Swiss cheese characterised by holes in the cheese that are made by one of the starter bacteria (propionic bacteria).

Grated and sliced Emmental has also been analysed and is safe to use. Processed forms, i.e. Babybel Emmental, are NOT suitable.

Gruyere is another mountain cheese made by adding rennet to the milk. The cheese is washed in a salt-bath and bacteria is added at a later stage.

Italian Parmesan is matured for a long period of time - at least one year and often two or more and as a result the lactose is leached out of the cheese. Parmesan is the common term for Parmigiano Reggiano DOP and it usually carries a DOP yellow and red seal to certify that it is made in Northern Italy. This type of parmesan is suitable. Ready grated parmesan which has the DOP seal is also suitable. DOP is the Italian abbreviation for PDO.American Parmesan is NOT suitable as it is often younger.

Jarslberg is a Norwegian cheese made in a similar way to Emmental.

Swiss farmers immigrated to Norway and took the recipe for Emmental with them, and presumably the starter culture too.

Comté is a French mountain cheese made by adding rennet to milk and adding salt later. It has a slightly sweet mild taste and is popular in France.

It is one of the oldest cheeses made in France, Records suggest it was made by shepherds in the 12th century Grana Padano is a slightly different type of parmesan made in another area of Northern Italy. Both block and grated forms of this cheese with the DOP seal are allowed. This is one of the world`s first hard cheese, as it was being produced over 900 years ago by the Cistercian monks of Chiarvalle near Milan.

Emmi Swiss Fondue is a mix of Emmental cheese potato starch and wine for making a cheese fondue.

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imd watch Traditional manufacture of cheddar cheese • Milk is heated ( pasteurised) and starter culture of bacteria is added specific for the farm and cheese • Rennet is added - it separates milk into curds and whey

Other suitable non-animal milk cheeses allowed in a low galactose diet Various soya and milk-free cheese options are suitable: • Cheezly (various flavours) - made by Redwood Foods • Pure Thick Cheese Slices • Pure Soft & Creamy Spread - a cream cheese style spread • Tofutti - soy cheese slices (mozzarella and American) • Tofutti “Better than cream cheese” - various flavours • Bute Island Sheese - 100 percent dairy free. All types of soy cheese (hard, cream, slices) in various flavours • No muh - vegan cheese squares, melty cheese, herb cheese and cheese with walnuts • Free & Easy Dairy Free - cheese flavour sauce mix • Parmazano - dairy-free grated replacement parmesan • Mozzarisella Creamy Risella - a creamy Italian vegan mozzarella cheese made from rice • Violife Creamy Original - classic cream cheese spread in a creamy consistency • Violife - Cheddar cheese block/slices • Vegourmet - Montanaro smoked vegan cheese slices • Jeezini - celtic cheddar-style vegan cheese block • Jeezy - natural vegan cream cheese • Bianco - vegan cheese - similar to mozzarella These cheese substitutes can be found in supermarkets, healthfood stores such as Holland

• • • • •

Curds are turned and cut - whey runs off Curds are salted Whey continues to drain away Cheese is formed into truckles and pressed Cheese matures in cool place for many months

and Barrett and online via sites such as Goodness Direct and Vegan stores.

CHEESE NOT ALLOWED IN GALACTOSAEMIA

1 Any other types of cheddar cheese not described in Figure 1.

2 All cheese added to manufactured foods, e.g. lasagne, cauliflower cheese, pizza, cheese pie, cheese sandwich 3 All soft cheese, e.g. Brie, Camembert, Roulade 4 All blue cheese, e.g. Stilton 5 All cheese spread, e.g. Dairylea, Philadelphia 6 Lactofree Products: Lactofree milk and cheese are not suitable because, although half of the lactose is removed, the rest is changed by enzymes into galactose and glucose. There is only a little lactose present, but there is plenty of galactose rendering them unsuitable.

7 Babybel is unsuitable as it is only fermented for a short time. The Emmental variety was tested by the GSG and contained some galactose (4).

CONCLUSIONS

This is a quick guide to suitable cheese in a low galactose diet. In practice, five types of branded cheddar and six types of mature hard cheeses that are very low in lactose and galactose and suitable for a low galactose diet. There is also a number of non-dairy cheeses that are appropriate to use. Although it is fabulous that so many cheeses are now permitted, caregivers are confused about which types they can use. As dietitians it is important that we are fully aware of the suitable cheese types so that we can accurately advise and support our families.

References 1 Portnoi PA, MacDonald A. Determination of the lactose and galactose content of cheese for use in the galactosaemia diet. J Hum Nutr Diet. 2009 22: 400-8 2 Portnoi PA, MacDonald A. Lactose and galactose content of cheese. In Preedy VC, Watson RR, Patel VB (editors). Handbook of cheese in health.

Wageningen Academic Publishers, Wageningen. 2013, p 495-516 3 Van Calcar SC, Bernstein LE, Rohr FJ, Scaman CH, Yannicelli S, Berry GT. A re-evaluation of life-long severe galactose restriction for the nutrition management of classic galactosaemia. Mol Genet Metab. 2014 112: 191-7 4 Portnoi PA, MacDonald A. The lactose content of Mini Babybel and suitability for galactosaemia. J Hum Nutr Diet. 2011 24: 620-1

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faltering growth

Faltering growth Faltering growth, previously known as failure to thrive (FTT) and also known as weight faltering, is the term used to describe infants and young children who fail to achieve expected growth for their age as measured by their weight and length or height and plotted on a suitable growth chart.

Kate Harrod-Wild Specialist Paediatric Dietitian, Betsi Cadwaladr University Health Board

This can be identified by the weight crossing two centile spaces downwards, or where a difference of more than two centile lines between the weight measurement and length or height persists over several measurements. Sometimes dietitians will see children, particularly infants, in their clinics who have been referred because of a low weight. However, this is meaningless in most cases if not accompanied by a length or weight measurement, as the child may simply be small, and primary healthcare professionals need to ensure that length or height is measured where concerns regarding weight emerge. However, if both weight and length or height is below the 0.4th centile, then this is considered abnormal and investigations should be carried out to try and establish the cause.

On the UK 1990 growth charts that were used until the mid-2000s, about five percent of children would have an episode of growth faltering. However, on the newer WHO growth charts, based on the slower pattern of growth of breastfed babies to

six months, only about 0.5% of babies are less than the 2nd centile at 12 months (1).

Historically, ‘failure to thrive’ was divided into organic and non-organic. However, this is now considered to be unhelpful, as few children with faltering growth have organic disease. The evidence suggests that organic disease is unlikely in children who are asymptomatic and well on examination, so that investigations should only be used to rule out rare major conditions (see Table 1) rather than to identify a cause of the faltering growth (2).

Routine weight monitoring should identify most cases of faltering growth; it is recommended that this should occur during the first week as part of the assessment of feeding and at eight weeks, 12 weeks, 16 weeks, one year (usually around the time of immunisations), and whenever concerns are raised. However, a population study of children with weight faltering found that although children were identified at a mean age of 15.5 months, the slowing of their weight

Table 1: Possible investigations to carry out in secondary care (2)

Kate Harrod-Wild is a paediatric dietitian with over 20 years of experience of working with children in acute and community settings. Kate has also written and spoken extensively on child nutrition.

Investigation

Indications

Possible cause

Full blood count Ferritin

Any persistent weight faltering Any persistent weight faltering

Urea and electrolytes

Any persistent weight faltering

Thyroid function tests Coeliac blood tests Mid-stream urine Chromosome analysis

Any persistent weight faltering Any persistent weight faltering Any persistent weight faltering Girls Infants under three months; history of chest infection History of respiratory infection Solid diet is limited, dark skin

Anaemia, leukaemia Iron deficiency Renal failure, electrolyte abnormalities Thyroid disease Coeliac disease Urinary tract infection Turner’s syndrome Cardiac abnormalities; cystic fibrosis Cystic fibrosis Rickets

Chest radiograph Sweat test Vitamin D levels

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faltering growth Table 2: Graded response to weight faltering (2)

Table 3: Relevant Symptoms • Colic • Vomiting • Reflux • Choking episodes • Wheezing

gain began in the early weeks and 50 percent had already crossed the screening threshold by age six months (3). Therefore, it is important that primary care health professionals, particularly health visitors, ensure that infants are weighed at the time of immunisations and that these are plotted in their primary health care record and action is taken where faltering growth is identified.

As shown in Table 2 (2), if slow weight gain is identified, the health visitor should carry out an assessment. This should include: • method of feeding; • number of feeds per day; • amount of time at the breast (and whether one or two breasts) or volume of formula taken; • for formula fed infants, the method of making up the bottle, the formula given, the type and size of teat; • any solids, number of times per day, foods given, amounts taken; • any feeding related problems - colic, constipation, vomiting, feed refusal; • any relevant psychosocial factors, e.g. maternal depression.

On the basis of this assessment, the health visitor should give any relevant advice and ask the mother to keep a record of fluids and foods given over a period of time, particularly if this unclear. The infant should be reweighed at a suitable interval. Optimal intervals and timings for measurement have not 34

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• Coughing • Eczema • Loose stools • Constipation

been formally established, but the Royal College of Paediatrics and Child Health suggest weighing no more than monthly before age six months, every two months aged six to 12 months, and every three months after one year (4). In practice, if there are concerns regarding weight gain, weight monitoring is probably going to occur more frequently.

If this does not improve the weight gain, then referral to the paediatric dietitian should be triggered.

The paediatric dietitian will ask similar questions to the above but will do so in more detail. They will also ask about: • feeding history - milks taken, age at weaning (if relevant), any problems; • relevant medical history; • any siblings; • any history of atopy; • any relevant symptoms (see Table 3).

They will explore the infant and child’s diet in detail including the following: Breastfeeding - if the child is breastfed, the dietitian will want to know if the baby latches on well - is there any slurping? Do they come off the breast frequently?

Does the baby feed from one breast or two? Does the Mother feel that the baby empties the breast?

Possible advice: • Ensure baby is latching on - signpost to breastfeeding counsellor.

• Ensure baby empties one breast before offering the other.

• If the mother produces lots of milk, consider expressing some milk before the start of the feed to ensure that the baby receives the energy rich hind milk.

The dietitian will try to avoid adding in formula unless absolutely necessary; if the infant is old enough, energy dense solids could be added in as an alternative.

Formula fed - the dietitian will try to establish the number of feeds per day given, how much feed is made up, how it is made up and how much formula

faltering growth is actually taken by the baby at each feed. The family should also be asked about the teats used and different formulas (if any) that have been tried and the reasons for switching. Families are not always very good at giving this information and this can make it difficult to establish how much the baby is actually taking. A calculation of how much the baby is taking in mls/kg should be made; on average, a baby preweaning should be taking approximately 150mls/ kg. Less or more than that is normal if the infant is thriving; caution should be exercised if the family contend that the infant is taking a lot more than 150mls/kg but is not gaining weight satisfactorily.

Possible advice: • If the actual amounts taken are unclear, then the parents should be asked to keep a record of actual amounts taken for three days.

• If the amounts taken appear to be excessive, but weight gain is poor, it needs to be established if this is because the infant is vomiting. In this case, reducing volumes may actually help to reduce vomiting and improve weight gain. A pre-thickened formula (e.g. Aptamil AR, SMA Staydown) or a thickener such as Infant Gaviscon or Carobel prescribed by the GP, may help reduce vomiting and increase weight gain.

• If the amounts taken seem much less than needed for weight gain, the reasons for this should be established. A history of vomiting, colic or wheezing may suggest gastro-oesophageal reflux (GOR) and, again, a prethickened formula or a feed thickener may help. If these do not help, then medication may be needed; some GPs may prescribe, but others may wish to refer to a Consultant Paediatrician in secondary care at this point. If it is not possible to improve volumes taken, then an energy dense formula (see Table 4) or energy dense solids or both (depending on age) may be appropriate. Care needs to be taken to ensure that increasing the calorie density of the formula does not simply reduce the volumes taken.

Older baby or young child on mixed diet - it needs to be established which foods and textures the child is accepting. Amounts offered versus amounts taken need to be clarified. Also the family needs to be asked about how many times a day the child is offered food. Intake of fluids - which drinks does the child have, how often and whether from

a bottle or cup needs to be known. At this age, the condition of dentition is also relevant and the family needs to be questioned about dental hygiene and visits to the dentist.

Possible advice: • Food needs to be offered at three meals and two to three snacks per day.

• Food needs to be calorie dense - and in reality that means high fat. Food should be fried wherever possible and cheese, cream, oil and butter used to fortify foods.

• Length of meals - meals should last no longer than 30 minutes; due to parental concerns regarding weight, in some households, meals can go on for an hour or two.

• Food should be taken away without comment if not eaten.

• Social eating - infants and young children should eat with the rest of the family wherever possible as social eating tends to improve intake. Every effort should be made to ensure that mealtimes are relaxed occasions.

• Fluids - over a year, drinks should be given from a cup, not a bottle. Adequate, but not excessive fluids should be given during the day; that means a small cup with each meal and snack, but children should not be allowed to sip on drinks throughout the day as this affects appetite.

• Wherever possible, food fortification should be used rather than nutritional supplements, as there is a danger that they may simply replace solid food. However, when asking parents to make changes, they can be useful to help manage parental anxiety. Wherever possible, they should be used on a short-term basis while food intake improves.

• Home visit - wherever possible, a home visit and observation of a meal can be key to discovering the root of a child’s feeding problems. In many cases this is not practicable or possible.

However, liaison with the Health Visiting service may mean that a Health Visitor or Nursery Nurse may be able to carry out the visit with a check list of observations to complete and report back to the Dietitian.

Particularly for infants who have atopic conditions or who have parents or siblings with atopic history (eczema, asthma, hayfever, allergic rhinitis), consideration should be given as to whether poor growth NHDmag.com April 2015 - Issue 103

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faltering growth Table 4: Specialist nutrient dense formulas for infants and milkshakes for older children Formula

Energy (kcals/100mls)

Protein (g/100mls)

90 101 100

2.0 2.6 2.6

100 101 150 151 150 150

2.4 2.8 3.4 4.2 3.8 3.0

Under one year/<8.0kg SMA High Energy Infatrini (Nutricia) Similac High Energy (Abbott) Over one year/>8.0kg Fortini 1.0 multifibre (Nutricia) PaediaSure (Abbott) Fortini Paediasure Plus (Abbott) Frebini energy (Fresenius) Resource Junior (Nestle)

is caused by cows’ milk allergy. However, further discussion of food allergy is out of the remit of this article.

For most infants and young children, poor weight gain will be short-lived and they respond to simple advice on calorie density and behaviour modifications, a minority may need advice from other professionals: • Speech and Language Therapist - where problems with textures are identified or there are any concerns regarding swallowing.

• Psychologist - particularly where parental anxiety is high and parents are finding it difficult to cope with their child’s eating behavior.

• Paediatrician - if a child’s calorie intake seems to be adequate and they are still not putting on weight, or if there are concerns about possible medical conditions, the child should be referred to a Consultant Paediatrician for assessment and, if appropriate, investigations (Table 2).

• Social Worker - historically it was felt that many children with faltering growth were suffering from abuse or neglect. Although this is now not the case, undoubtedly poor growth can be a symptom of emotional deprivation. Where a paediatric dietitian has any concerns of this nature, or sees clear evidence of major social problems, such as drug or alcohol abuse, they

should speak to their line manager and the child’s health visitor and/or GP as appropriate. Where concerns persist, the family should be referred to the social work team for assessment and this may result in a child being treated as a ‘child in need’ or entry on to the child protection register after investigation of the family’s circumstances.

In some areas, feeding teams are available, containing a combination of some or all of these professionals. This is a more efficient way to deal with difficult feeding behaviours as there can be a single assessment and more streamlined signposting to the appropriate professionals.

Faltering growth can be very distressing for a family, especially for mothers, who are ‘programmed’ to feed their children. A sensitive, multidisciplinary approach can help families regain their confidence to feed their children. In most cases, relatively simple measures, along with reassurance, can restore a normal pattern of weight gain. Where this is not possible, a thorough assessment and a stepwise approach give the best chance of establishing the cause of the faltering growth. Even when this is not possible, the family need to have confidence that the dietitian will support them along the path to restoring normal growth and will refer them to the appropriate professionals to ensure that this occurs.

References 1. Wright C, Lakshman R, Emmett P, Ong KK. Implications of adopting the WHO 2006 Child Growth Standard in the UK: two prospective cohort studies.

Arch Dis Child 2008; 93: 566-9 2. Shields B, Wacogne I, Wright C. Weight faltering and failure to thrive in infancy and early childhood BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj. e5931 (accessed 8.10.14) 3. Wright C, Birks E. Risk factors for failure to thrive: a population-based survey. Child Care Health Dev 2000; 26: 5-16 4. UK Department of Health. Using the new UK-World Health Organisation 0-4 years growth charts: information for healthcare professionals about the use and interpretation of growth charts. Department of Health, 2009

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(previously Nutramigen AA)

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A new and improved hypoallergenic amino acid-based formula for severe CMA and multiple food allergies:

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A solution for all your CMA needs Reference: 1. Burks W et al. J Pediatr 2008;153:266–271. †This study was conducted with Nutramigen AA without MCT oil.

IMPORTANT NOTICE: Breast milk is the best nutrition for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. Failure to follow preparation instructions carefully may be harmful to your 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. © 2015 Mead Johnson & Company, LLC. All rights reserved. This material is for healthcare professionals only.

EU15.509. January 2015

cancer care

Nutrition in cancer care Cancer is a major cause of death and morbidity in the UK and 29 percent of deaths were caused by it in 2011. Approximately 159,000 people died in 2011 in the UK from various types of cancer (1). Lung, bowel, breast and prostate cancer are the most common forms of cancer and account for over half of the causes of death.

Dr Mabel Blades Independent Freelance Dietitian and Nutritionist

Advice to those being treated for various types of cancer on nutrition can be of vital importance to enhancing the outcome of treatments, as well as feelings of wellbeing. Thus the role of the Registered Dietitian in undertaking such work can be important to outcomes.

Screening and treatments for various types of cancer mean that nowadays many more people diagnosed with the condition survive than did in the past.

Malnutrition is associated with cancer and indeed can be one of the symptoms that cause individuals to seek a GP appointment and to commence the pathway to the diagnosis of cancer. The complication of malnutrition in cancer can adversely affect the outcome of treatment (2). Unfortunately about 40 percent of those with cancer have been found to suffer from protein energy malnutrition (3). In those with head and neck cancers this can increase to 80 percent.

Factors causing cancer

Dr Mabel Blades is a member of the BDA and NAGE, Food Counts and Freelance Dietitians specialist Groups.

As a Registered Dietitian she is passionate about diet and that anyone with a diagnosis of cancer gets the best nutritional advice possible.

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Lifestyle factors of diet (including obesity) have been well recognised with the development of various forms of cancer. Indeed, the World Cancer Research Fund in 2007 in their comprehensive report on the subject of ‘Food, Nutrition, Physical Activity and the Prevention of Cancer; a Global Perspective’, considered that up to 35 percent cancer cases throughout the world are preventable by dietary means (4).

The following associations of diet with a higher risk of cancer are found:

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• Obesity with endometrial and breast cancer.

• Lack of fibre and colon cancer.

• High intake of meat and meat products with colorectal cancer.

• Excess alcohol with liver cancer.

• High salt intake with stomach cancer.

• One of the key dietary aspects associated with a lower incidence of oral, pharyngeal, laryngeal, pancreatic, lung, colorectal, breast and prostate was considered to be a lack of fruit and vegetable consumption.

Accordingly the World Cancer Research Fund made various recommendations to rectify this: • Be as lean as possible within the normal range of body weight.

• Be physically active as part of everyday life.

• Limit consumption of energy-dense foods and avoid sugary drinks.

• Eat mostly foods of plant origin.

• Limit intake of red meat and avoid processed meat.

• Limit alcoholic drinks.

• Limit consumption of salt and avoid mouldy cereals (grains) or pulses.

• Aim to meet nutritional needs through diet alone.

• Mothers to breastfeed children.

• All cancer survivors to receive nutritional care from an appropriately trained professional if able to do so and, unless otherwise advised, aim to follow the recommendations for diet, healthy weight and physical activity.

cancer care For the first time, the report made a recommendation as regards to those diagnosed with cancer and the need for advice. An overview of such information in respect of these recommendations is provided by Cancer Research UK (5).

The multidisciplinary team and the role of the RD

Unfortunately, attention to nutrition may be neglected in the turmoil of treatments for the condition. There is also a lack of information on nutrition intervention studies to demonstrate the best method of support. Such interventions can include chemotherapy, radiation or surgery, as well as other medications. Chemotherapy can have various toxic side effects such as loss of appetite, nausea, vomiting and fatigue which can in turn lead to malnutrition. Consideration of nutrition and the assessment of malnutrition and the management of this is vital to the outcome of treatments and is a recommendation in NICE guidance (6). As long ago as 1992 Professor Leonard Jones proposed such a team approach in the Kings Fund report on ‘A positive Approach to Nutrition as Treatment’ (7). Registered Dietitians can be key members of such teams.

Malnutrition screening

People suffering from cancer are at greater risk of malnutrition which can be due to factors such as: • the site of the cancer; • the tumour growing and increasing the metabolic rate, plus causing problems like vomiting, diarrhoea or reduced absorption; • anxiety and depression leading to a distorted or diminished appetite; • treatments such as surgery, chemotherapy, radiotherapy and medications which may have profound effects on the gastrointestinal tracts.

The form of malnutrition ‘Cancer Cachexia’ is associated with weight loss, reduced muscle strength, tiredness and anorexia and is seen in 50 percent of those with cancer, particularly advanced cancers. This condition is accompanied by not just a loss of body fat but also muscle tissues and a resultant weakness. The condition is complex and includes various biochemical pathways including tumour necrosis factor and it is

hoped that pharmacological agents can be produced to reverse the condition (8).

Such malnutrition may well be a factor in the negatively affecting clinical decisions such as further interventions and, in particular, surgery.

It can also have a detrimental effect on healing and recovery, as well as being associated with an increased risk of complications. Therefore, it is recommended to screen those suffering from cancer so that early nutritional interventions can be made. The Malnutrition Universal Screening Tool (MUST) produced by BAPEN is a well-known and useful tool for the assessment of malnutrition and is a five-step screening tool to identify adults who are malnourished, at risk of malnutrition (under-nutrition), or who are obese.

Care plans

From the assessment of malnutrition, a care plan should be developed for the individual concerned. This care plan may include the use of various steps, including the use of energy dense foods, fortification of meals, recording food intake, and the use of prescribable supplements to increase calories and protein, as well as the referral to a Registered Dietitian.

If an inadequate intake is taken orally then enteral feeding may be recommended, which may provide total or supplementary nutrition.

Indeed, trials have shown that enteral feeding of patients after gastrointestinal surgery for cancer showed an improved recovery time, plus cost benefits (9).

Nutrition in hospital

Those who are malnourished fare less well as regards the clinical outcome. Therefore, monitoring weight as described using the MUST and if required increasing the calories in the diet, can be invaluable in helping to prevent weight loss.

The British Dietetic Association (BDA) has produced a comprehensive resource on nutrition and diet for hospital patients called The Nutrition and Hydration Digest (10). This contains recommendations for nutritionally vulnerable patients and could include those who have experienced weight loss due to cancer.

Such recommendations include an energy target of 1,800 to 2,100 kcal per day for a 60kg NHDmag.com April 2015 - Issue 103

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cancer care weight patient and 2,250 to 2,625kcal per day for a 75kg weight patient, plus a protein target of 1.0g per kg body weight. This is usually provided by three meals and two higher energy snacks per day, as well as possibly additional supplements.

A higher calorie meal comprising of a starter, main course and pudding should thus provide 800kcal. For practical purposes, to achieve this, soups must be nourishing and provide at least 100kcal per portion and 3.0g of protein. If a snack meal is chosen such as a sandwich or salad then this should achieve the same amount of energy.

The higher energy between meal snacks should provide in two snacks 300kcal and 4.0g protein.

Both chemotherapy and radiotherapy may cause mucositis due to the effects on the oral cavity, including the salivary glands and may cause a dry or sore mouth which results in difficulties in chewing and swallowing. Hospital menus are recommended to include a soft choice of food which is easy to eat for such patients.

Neutropenic diets

During cancer treatments, the immune system can be compromised. During this phase, a neutropenic or ‘clean’ or ‘low microbial’ diet is used to protect the patient from infections. There is considerable variation in what is considered to be a neutropenic diet between centres in the UK and abroad (11).

Comprehensive information is provided by the BDA for both a neutropenic diet and another for profound neutropenia. Suitable diet sheets can be provided by local Registered Dietitians.

Key points:

• Wash hands.

• Wash crockery and cutlery well at a high temperature preferably in a dishwasher - disposable cutlery and crockery can be used on occasions where this is not possible.

• Make sure any food is thoroughly cooked and served while piping hot.

• Avoid items like unpasteurised cheeses and blue veined cheese, uncooked meats and fish like sushi, plus smoked fish and hams, raw eggs such as in homemade mayonnaise and probiotic products.

Micronutrient deficiency

There are reductions in micronutrient levels in those with cancer versus healthy controls (12). Some studies have looked at the supplementation of the diet with additional micronutrients with beneficial results in prostate cancer (13).

Bone health

Some of the hormonal therapies used in cancer treatments, forms of chemotherapy, as well as surgery on the ovaries or testes can have adverse effects on calcium metabolism due to the effect on oestrogens and testosterone (14). Therefore, supplements of vitamin D and calcium can be provided to maximise bone health.

Conclusion

Registered Dietitians can have an important role in nutrition in cancer care and such improved nutrition can have numerous beneficial effects.

References 1 Cancer research UK, accessed July 2014, http://publications.cancerresearchuk.org/downloads/Product/CS_CS_MORTALITY.pdf 2 Santarpia L, Contaldo F and Pasanisi F (2011). Nutritional Screening and Early Treatment of Malnutrition in Cancer Patients. J Cachexia Sarcopenia Muscle. March 2011. 2(1) 27-35 3 Ravasco P et al (2003). Nutritional Deterioration in Cancer: the Role of Disease and Diet. Clinical Oncology 15 p443-450 4 World Cancer Research Fund (2007). Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective. World Cancer Research Fund.

5 Cancer Research UK. www.cancerresearchuk.org/cancer-nfo/healthyliving/diet-healthy-eating-and-cancer/diet-healthy-eating-and-cancer Accessed September 2014 6 National Institute of Clinical Excellence (NICE) (2004). Improving Supportive and Palliative Care for Adults with Cancer. The Manual. London 7 Jones LJ (1992). A positive Approach to Nutrition as Treatment. Kings Fund Report 8 Laviano A et al (2008). Neural control of anorexia-cachexia syndrome. American Journal of Physiology Endocrinology and Metabolism. 295 E1000-1008 9 Barlow R et al (2009). Randomised control trial of early enteral nutrition versus conventional management in patients undergoing major resection for upper gastrointestinal cancer. NCRI conference 2009 10 British Dietetic Association, accessed Dec 2012. www.bda.uk.com/publications/NutritionHydrationDigest.pdf 11 Mank AP et al (2008). Examining low bacterial dietary practice. European Journal of Oncology Nursing 12 (4) 342-348 12 McMillan DC et al (2000). Changes in micronutrient concentrations following anti-inflammatory treatment in patients with gastrointestinal cancer. Nutrition 16 (6) 425-428 13 Thomas R et al (2007). Can dietary intervention alter prostate cancer progression? Nutrition & Food Science. 37(1) 24-36 14 Macmillan Nurses, accessed Dec 2012. Nutrition Treatments and Bone Health (booklet) www.macmillan.org.uk/Cancerinformation/ Livingwithandaftercancer/Eatingwell/Eatingwell.aspx

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Dementia and nutrition

Adopt a Care Home (AaCH) and Dementia Awareness: a Sheffield pilot The prevalence of dementia increases with age. There are approximately 800,000 people currently living with dementia in the UK, with this figure set to double over the next 40 years (1). In 2010, the total number of people with dementia worldwide was estimated to be 35.6 million by the World Health Organisation (2).

Andy Wallace Commissioning Officer for Quality, working in Adult Social Care for Sheffield City Council

As Commissioning Officer, Andy has to ensure that all care homes and other relevant services are up to date with all legislation linked to care.

He developed the ‘Adopt a Care Home’ pilot, as he already had links with schools as a School Governor. Andy enjoys his garden and garage, tinkering about on a weekend and confesses to being an active healthy eater.

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This figure is projected to double every 20 years. The total number of new cases of dementia each year, worldwide, is nearly 7.7 million, implying one new case every four seconds (2).

Although dementia mainly affects older people, it is not a normal part of ageing. Dementia is a syndrome, usually of a chronic or progressive nature, caused by a variety of brain illnesses that affect memory, thinking, behaviour and ability to perform everyday activities (2).

In Sheffield, around 6,400 people aged 65 or over are living with some form of dementia. This number is expected to increase to 7,400 by 2020 and to 9,400 by 2030. The biggest increase is likely to be in the numbers of those aged over 85 and that almost a third of those with dementia currently live in care homes in the city, with others living in the community often supported by family carers. People with dementia are more likely to be admitted into long-term care after a hospital stay than returning to their own home.

Sheffield Integrated Commissioning Plan for people with dementia and their carers designed for 2014/15 was to ensure the delivery of excellent health and wellbeing outcomes for people with dementia in Sheffield, maintaining value for money. Effective commissioning and partnership working with key stakeholders are enabling this plan to be achieved.

Understanding dementia and its effects is an important part in under-

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standing, living with and coping with dementia. Schools can play a vital role in the development of dementiafriendly communities. By educating children and young people about dementia, a dementia-friendly generation can be created - a generation that is more aware of dementia and more supportive of people with dementia in the community where they live. And just as importantly, if not more so, by talking to children and young people about dementia, it can reassure them about their fears and misunderstandings and help them to relate to grandparents and other family members who may have dementia.

The Sheffield Dementia Action Alliance oversees the establishment of Sheffield as a dementia-friendly city and provides information about the national work with schools - to establish a dementia aware generation. The Alzheimer Society believes that engaging young people is crucial to the development of dementia-friendly communities. The Society previously funded Dementia4Schools and now runs the project in house. Adopt a Care Home is a fantastic model, improving links between care homes and schools and improving inter-generational relationships.

The Adopt a Care Home (AaCH) pilot intended to involve children in increasing the quality in care homes.

It was planned to integrate stronger links with schools and care homes in a geographic area so that schools can ‘adopt’ a care home. The pilot pro-

Dementia and nutrition posed the following work and expected outcomes: • Increase awareness about the older population in Sheffield as many younger children may not have experienced an ‘older’ person’s view.

• Help younger people to understand the challenges of dementia and reduce the stigma associated with this.

• Assess reading and writing skills of the children by giving them the opportunity to read with the older people and to also write either a ‘life story’ for the older person, or at least write about their experience of meeting older people.

• Integrate children within the care home population to enable them to develop and grow by learning about older people’s experiences. This will not only support growth and maturity, but also give clear outcomes around basic skills with integration.

• Make the care home that has been adopted a talking point in class and the opportunity for children to reflect.

• Offer older people in care homes the opportunity to offer their experience and skills and give something to their community.

A programme for learning was devised in conjunction with the pilot primary school, (Prince Edward Primary) and two care homes in close proximity to the school. This was implemented from September 2014 and qualified teachers delivered the dementia programme.

The children were encouraged to walk to their partner care home and ‘walking buses’ made regular trips. There had been many homes in Sheffield showing interest in being involved in the pilot, and it is hoped that there will be a wider ‘Adopt a Care Home’ initiative linked with a local school in the future.

The initiative intended to support the wider outcomes expected from the Care Quality Commission (CQC) and encourage community cohesion. It was anticipated that education and learning would be enriched and, more-

over, benefit the quality of provision at the care home. The AaCH initiative aimed to become an integral part of the activity programme within each home. The positive activities included: • Life Story Work Dementia UK Life Story (3) or This is Me (4); • mini autobiographies created by the children for the resident; • reminiscence - involving the children in asking questions and finding answers; • wider learning for the residents - children supporting residents with helpful technology; • intergenerational understanding - allowing the residents to discuss about their life, enabling the child to learn about the past; • eating and drinking together, increasing the residents desire to enjoy the interaction and unknowingly increase what was eaten and drunk; • researching the roles of carers and personnel involved with care homes.

Learning from the programme has been covered in team meetings and in specific 1:1 sessions with the appropriate staff. There is also support via the Dignity Network facilitated by myself as well as an agenda item on the quality visits that I undertake. Questionnaires have also been designed for the school children to assess their awareness of dementia pre- and post-pilot.

An evaluation will be completed with support from Scharr, part of Sheffield University.

The outcomes will focus on: 1 that the young people being taught about dementia have a better understanding of dementia and its impacts; 2 that the residents of the care home have a meaningful and positive interaction with young people from the community.

It is anticipated that if the pilot is successful and there is agreement from all relevant stakeholders, that a joint bid for further funding will be submitted to evaluate a city-wide programme for AaCH and Dementia Awareness.

References 1 Dementia 2013. The hidden voice of loneliness - Alzheimer’s Society www.alzheimers.org.uk/dementia2013 2 Dementia: a public health priority, World Health Organisation and Alzheimer’s Disease International, 2012 3 Thompson R (2011). Using life story work to enhance care. Nursing Older People 23 (8): 16-21 4 This is Me tool, Alzheimer’s Society, 2013

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efad

DieƟetics in AƟens 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.

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Delegates attending the EFAD Athens Conference number eight, ate lots of local delights. Plates were mountain-high with souvlaki, salads and spanakopita.

Aside from eating together, there were lots of opportunities to compare and contrast the science and practice of dietetics in a melody of European accents, the unfair constant being that the official language of the event (=English) was not the mother tongue of the vast majority of those attending.

The European Federation of the Associations of Dietitians (EFAD) was established in 1978 to encourage both the better nutrition status of the population of the member countries of Europe, and to support the scientific and professional development of dietetics, with a view to entwining these two public and professional strands. Membership of EFAD is open to all National Associations of Dietitians from member states of the European Union, and there are currently 33 member associations (of which the BDA is one), representing over 30,000 dietitians. In addition to funding from member associations, EFAD receives funding from the Executive Agency for Health and Consumers, under the framework for the Health Programme of the European Union.

The EFAD Athens conference held in October 2014, offered a rich diversity of themes to consider and, at all times, there were three to five parallel events to choose from. Over the threeday conference, there were 16 lectures, 10 workshops and 21 roundtables and, as always with a large conference, some preparation time is needed to blend learning the most with rushing around the least.

There were many star speakers.

French sociologist Claude Fischler offered dazzling insights into the many ways that we think about food and how this influences food choices. Questions on foods show particular polarity between American versus French re-

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spondents, and Professor Fischler has researched these differences in depth.

Prompted with pictures of chocolate cake, Americans think “guilt - calories”, whereas French think “celebration - pleasure”. A picture of a jug of cream makes Americans think “unhealthy”, whereas French think “whipped”. Professor Fischler observed that when looking at the many risk factors there were for obesity, the one that consistently scored highest was being an English-speaker.

Americans valued quantity, variety and comfort, whereas the French selected quality and pleasure-giving to explain their food choices. For a sociologist to observe that people are muddled and inconsistent in their views is not stopthe-press news, but Claude Fischler also gave some historical examples of strident pronouncements of the healthiness of foods that would today elicit opposite opinions. The obvious thought is which of our current dietary guidelines will amuse future nutrition professionals?

Today his main area of research is commensality - eating together and sharing food - and possible effects on public health; eating a lunchtime sandwich al desko is unlikely to score well, but can the who-you-eat-with really out-trump the what you eat in relation to health?

Another internationally acclaimed speaker was James Hill, best known for the establishment of the National Weight Control Registry (NWCR) in the US. This project is an inversion of the normal research project; rather than ex-

efad perts giving advice on weight control, it involves recruiting those who have been successful at losing significant amounts of weight (at least 35kg), and maintained this loss for at least a year, and then collecting information on habits and beliefs associated with success (positive deviance).

Typical NWCR members are female, aged 45-50.

Nearly half of the subjects have lost weight on their own, whereas the others had the support of a health professional or some weight loss organisation. Overall, common patterns for successful weight loss maintenance were breakfast eating, the use of low-calorie sweeteners, regular self-weighing and doing some vigorous physical activity for an hour daily. Changes to lifestyle required dedication and determination and Professor Hill contrasted tales of success with some examples of the social costs of weight loss, such as no longer meeting the friends who gathered weekly over beer and pizza.

There has been a levelling off of obesity trends in the US population and Professor Hill discussed commentary on this. Was there a saturation of those within the population who were genetically susceptible to weight gain in a foodrich environment? Was it an increased availability of products that supported small changes to lifestyle choices, such a replacement of energycontaining drinks with low calorie alternatives?

“Any (energy-deficit) diet works,” concludes America’s most authoritative weight loss expert, but the urgent issue is now to better understand and support weight maintenance. Nutrition professionals needed to improve matching weight loss therapies to the specific needs of dieters, and more effort was needed to screen out ‘not ready for weight loss’ patients from programmes in order to reduce disappointment on both sides of the consulting table.

A star-of-the-future is Aimilia Papakonstantinou, a dietitian who lectures at the Agricultural University of Athens. She spoke about the use of low calorie sweeteners for people with obesity or diabetes mellitus. Low calorie sweeteners are assessed for safety by both European experts (EFSA) and experts supported by the United Nations and the World Health Organisation (JECFA). Regulatory agencies use data to then define ‘Acceptable Daily Intakes’ levels, the amount of an approved sweetener that can be consumed

daily over a lifetime, without any anticipated health problems. Of course, all sweeteners in use have been approved by expert agencies as safe, but there were often public concerns over concepts of natural versus artificial ingredients in foods. Dr Papakonstantinou referred to the importance of evidence-based data as the basis for dietetic advice and, from this, the use of approved sweeteners could be supported. But did the use of sweeteners support health in those who were overweight and in those with diabetes? One study showed that the inclusion of non-nutritive sweetened drinks was at least as effective as drinking water, during a 12-week weight loss programme (Peters JC et al, Obesity, 2014). Another review showed that the inclusion of low-calorie sweeteners, in place of regularcalorie choices, supported modest weight loss (Miller PE, AJCN, 2014). Some observational studies reporting positive associations between obesity and the use of low-calories sweeteners may represent ‘reverse causality’ whereby being obese increases the chance of seeking products containing sweeteners.

The session on hydration brought in a local theme: fluid balance in the citizens of Athens.

Maria Kapsokefalou of the Agricultural University of Athens has researched the effects of seasonality on water balance. The significant differences in summer and winter temperatures in Greece resulted in strong differences in typical intakes of fluids of one litre per person daily.

Mean intakes of total water intakes in a sample of Athenians was 2,892ml per day in the winter, rising to 3,875ml per day in the heat of summer.

Professor Kapsokefalou observed that generally water balance was tightly maintained so that measured intakes matched measured outputs; however, there were more subjects with aberrant water balances in summer, indicating that it was more difficult to remain hydrated during periods of heat.

During discussions on hydration status, there may be some differences in concept between the public and scientific use of terminology. Public understanding of the term ‘water’ may only include the clear fluids consumed from a glass or a bottle and not the 20 to 30 percent of water intakes also provided by solid and formed foods, so advice on water intakes may cause confused NHDmag.com April 2015 - Issue 103

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efad and exaggerated public perceptions of requirements. Some consistency of the terms ‘waterfluid-liquid’ would be useful in public health messages, otherwise correct science information outputs may be lost-in-translation. But this is what dietetics is all about anyway.

Professor Ron Maughan from Loughborough University presented interesting views on the question of why drink? No debate is needed to support the view that more people should be more active more often, but of interest is the data showing that subjective perceptions of the general effort of running-around are increased during states of greater dehydration. Studies of identical exercise tasks showed increases in the self-assessments of effort needed, when intakes to hydration are restricted. When there are so many items on the public list of “why I can’t be bothered to exercise”, impairment of the easiest one to rectify, hydration status, should always be

considered during advice on fitness. Peak performance is not usually the concern of recreational exercise, and health and wellness benefits more strongly drive participation. However, one valid reason to moderate effort during exercise is heat, and Professor Maughan described data showing the adverse effects of greater leakage across the blood-brain barrier as environmental temperatures increased.

The website ‘efad.org’ will be the site to check for future events and conferences. Attending an EFAD conference is a wonderful opportunity for a science and practice update on dietetics. And a wonderful opportunity to visit a European city: Amsterdam is next on the list.

Declaration Ursula’s attendance at the 8th EFAD conference held in Athens on 9-12 October 2014, was kindly funded

by The Coca Cola Company

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web watch

web watch Online resources and useful updates.

Quality standard: Inflammatory bowel disease NICE has published a new quality standard Inflammatory bowel disease (QS81). This quality standard covers the diagnosis and management of inflammatory bowel disease (Crohn’s disease and ulcerative colitis) in adults, children and young people. www.nice.org.uk/ guidance/qs81 Allied Health Professionals prescribing plans Proposals allowing certain health professions to prescribe or supply and administer medicines for patients have been published

by NHS England. The proposals would apply across the United Kingdom and would enable four groups of registered allied health professions (AHPs) radiographers, paramedics, dietitians and orthoptists to prescribe or supply and administer medicines, giving patients responsive access to treatment. For many patients, an AHP is their lead clinician, yet they often do not have access to the appropriate prescribing or supply and administration of medicines mechanisms. This means that the patient may have to make an additional appointment with their GP or doctor to get the medicines they need. www.england.nhs. uk/2015/02/26/access-tomedicines/

Sugars intake for adults and children The World Health Organisation has published a guideline Sugars intake for adults and children. The objective of this guideline is to provide recommendations on the intake of free sugars to reduce the risk of noncommunicable diseases in adults and children, with a particular focus on the prevention and control of unhealthy weight gain and dental caries. The recommendations in this guideline can be used by policymakers and programme managers to assess current intake levels of free sugars in their countries relative to a benchmark. They can also be used to develop measures to decrease intake of free sugars, where necessary, through a range of public health interventions. www.who.int/ nutrition/publications/guidelines/ sugars_intake/en/ National NHS Diabetes Prevention Programme Public Health England, NHS England and Diabetes UK have announced local demonstration sites for the new National Diabetes Prevention Programme. The programme aims to significantly reduce the four million people in England otherwise expected to have Type 2 diabetes by 2025. It is estimated that a big proportion of Type 2 diabetes could be prevented, and England will be the first country to implement a national evidence-based diabetes prevention programme at scale. Seven ‘demonstrator’ sites (including Bradford CCG) have been chosen to take part

in the initial phase of the programme, during which they will see more patients, monitor and test their local programmes and help co-design and implement the national programme. www.gov.uk/government/news/ national-nhs-diabetes-initiativelaunched-in-major-bid-to-preventillness

NICE guidance: maintaining a healthy weight for adults and children NICE has published Maintaining a healthy weight and preventing excess weight gain among adults and children (NG7). This guideline makes recommendations on behav- iours that may help people maintain a healthy weight or prevent excess weight gain.

The recommendations support those made in other NICE guidelines about effective interven- tions and activities to prevent people becoming overweight or obese. This includes interventions and activities in which weight is not the primary outcome, such as those aimed at preventing cardiovascular disease or Type 2 diabetes, improving mental wellbeing or increasing active travel. The guideline covers children (after weaning) and adults. It does not cover the particular needs of women during pregnancy or people who have conditions that increase their risk of being overweight or obese. The guideline is for practitioners who use related NICE guidance and need advice on behaviours that may help people maintain a healthy weight and prevent excess weight gain.www.nice.org.uk/guidance/ng7 NHDmag.com April 2015 - Issue 103

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career

NHDmag.com . . .

. . . Your essential resource 48

NHDmag.com April 2015 - Issue 103

career

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

ROYAL BROMPTON HOSPITAL - ADULT CARDIORESPIRATORY DIETITIAN (INCLUDING PRIVATE PATIENTS) - BAND 7 £36,917 - £46,837 permanent, full time NHS Jobs ref: RB/RS/4539 Royal Brompton & Harefield NHS Foundation Trust is the largest heart and lung centre in the UK and among the largest in Europe. We are looking for an enthusiastic and experienced Specialist Dietitian (minimum five years post-qualification) to join our proactive Rehabilitation & Therapies Directorate. This new post is based in our dynamic multi-professional Adult Heart Services Therapy Team and has been created to develop Specialist Dietetic outpatient services whilst providing acute inpatient care for patients on our private ward.

Additionally, you will work closely with The Trust Nutrition Lead providing nutritional support to complex intensive care patients including those on ECMO treatment. The successful candidate will be supported by strong working relationships directly within the therapy and multidisciplinary team. The post is suitable for someone with significant experience in acute care, preferably within cardio-respiratory, combined with excellent communication skills and a willingness to enhance practice. For more information please contact: Dr Ione de Brito-Ashurst, Nutrition Lead for the Trust and Governance & Safety Lead for Rehabilitation and Therapies on i.ashurst@rbht.nhs.uk, www.jobs.nhs.uk.

Closing date 30 April 2015.

Band 6 Dietitian Community - Learning Disabilities Band 6 Dietitian required for a full-time community position working in learning disabilities and will therefore need to be able to transport themselves around Norfolk. Support will be provided by the Clinical Lead Specialist Learning Disability Dietitian, but the locum will need to be confident with working independently in the community. Ideally, the locum will have experience in learning disabilities/mental health, but if not, good general community clinical experience and knowledge would be essential for this role and also the ability to be creative with how advice is provided to the clients. MDT experience would also be helpful,

as communication with many different carers/health professionals is needed to support the clients. Accommodation is available. Ideally starting on 13th April 2015 for two to three months. Please call 01277 849 646 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com Band 6 Dietitian - Stoke on Trent Band 6 Dietitian required for a part-time three-daysa-week role in Stoke on Trent covering acute Adult work across three sites, applicant must be able to commute between the sites. Start date is April for four weeks. 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 Band 6 - Diabetes and Nutrition Support Band 6 Diabetes and Nutrition Support Dietitian to cover a full-time community role in Wigan. For this or other dietetic vacancies with Elite, please contact Hayley on 01277 849 649 or email your CV and interest to hayley@eliterec.com www.elitedietitians.com Dietitian required for weightloss company We are recruiting again for an exclusive weightloss company based in Central London. We have been retained by London’s fastest growing weightlost company to recruit an outgoing and entrepreneurial dietitian. This client specialises in body transformation programmes with an intelligent combination of fitness, nutrition and lifestyle support. The successful applicant will join a vibrant team already consisting of one dietitian. Your primary role will be to provide outstanding dietary advice to their client base, offering support to help them achieve extraordinary results and increase client retention. You will also help develop existing plans and help to improve processes, documentation and materials which accompany the clients’ programmes. To be considered for this role, please email Hayley@eliterec.com or call 01277 849 649. www.elitedietitians.com Continued . . .

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CAREER Band 6 Acute Dietitian kent Band 6 Acute Dietitian required for an NHS Hospital in Kent. This post is full time covering acute wards starting April for two months. Please call 01277 849 649 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com

Paediatric Diabetes Dietitian - Bristol Band 6 Paediatric Dietitian required to cover general outpatients and Diabetes in Bristol from April for two months. Accommodation is available on site. Please call 01277 849 649 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com

events and courses University of Nottingham - School of Biosciences Modules for Dietitians and other Healthcare Professionals • Diabetes 1 & 2 - 14th May 2015 • Renal Nutrition - 19th May 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’.

16th May - Paediatric Nutrition University of Nottingham - School of Biosciences Modules for Dietitians and other Healthcare Professionals - www.nottingham.ac.uk/biosciences

12th May - Nutrition and Survivorship: Nutritional Issues Following Cancer Treatment The Royal Marsden Education and Conference Centre, London SW3 6JJ www.royalmarsden.nhs.uk/education/ 19th May - Eating & Nutritional Care for Older People with Dementia One-Day Conference mediacpd.com 20th to 22nd May - COPOC Tel Aviv 2015 1st International Conference on Controversies in Primary and Outpatient Care - Tel Aviv, Israel www.comtecmed.com/copoc/2015/

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

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www.pjlocums.co.uk 50

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The final helping

Neil Donnelly

It was the summer of 1966, the height of the Swinging Sixties, England had won the World Cup and a young boy from the Welsh Valleys was about to start his four-year Nutrition and Dietetics Degree Course.

Based in Battersea, South of the Thames, I was looking forward to both the course and experiencing the ‘London Scene’.

Little did I know that up the road at Ealing Technical College the year before, one of the most intelligent, influential and empathetic dietitians of my generation had started her dietetic training.

. . . her commitment to the Dietetic Profession could not have been more obvious and her name will be known and revered by hundreds . . .

Neil is a Fellow of the BDA and retired Dietetic Services Manager.

His main areas of interest are weight management and eating disorders

Over the years I got to know Pat Judd well enough to call her a friend. Her professional achievements are many, but for me, two things stand out. One is the 25 years that she was the Course Coordinator for Dietetics at Kings College London. The other was her Editorship of our professional journal Nutrition and Dietetics. In both of these roles, her commitment to the Dietetic Profession could not have been more obvious and her name will be known and revered by hundreds, if not thousands, of dietitians practising today.

Pat later became Professor of Nutrition and Dietetics at the University of Central Lancashire in Preston, which was a stone’s throw from my place of work in Blackpool. We were honoured

to have such a distinguished and approachable person close by, close enough for me to ask her to be on the Editorial Board on the short-lived successor to the BDA Adviser magazine.

She, of course, accepted despite her many other commitments.

Pat’s illness arrived with little warning early in February. Her death was announced on 6th March. Her funeral on 16th March at Preston Crematorium was attended by many former colleagues and friends, some who had travelled long distances. Tributes were given by Moira Nash and Margaret Lawson, her friend and colleague of 50 years since student days at Ealing. We also learned more about the family side of Pat and her hobbies of narrow-boating and amazing skills in textiles and quilting. Tony, her husband of just a few days and partner for some 37 years, has requested that an Award be set up in Pat’s memory. This is a BDA award to recognise the overwhelming contribution that one person has made to the evidence based practice of Dietetics and the attitudinal approach that we should all be offering to those we wish to help.

Pat laid down a marker for us all and I hope that our professional association will, as they have done already with her Fellowship in 1998, take this opportunity and seek advice as to the most appropriate way forward to recognise the contribution of this remarkable, respected and much missed colleague and friend.

NHDmag.com April 2015 - Issue 103

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Cow’s Milk Allergy Management

THE UNIQUE RANGE FOR ALLERGIC CHILDREN 0-10 YEARS

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The unique spoo that can be us nable produc t ed as a dairy replacement for allerg ic ba bies and children from 6 month s+

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Working together for better paediatric care