News

dr emma derbyshire Phd rnutr (Public health) nutritional Insight ltd We are all aware that eating fruit and veg is good for us. Previous research has shown that eating fruit and veg offers a number of important health benefits, particularly in relation to coronary heart disease (CHD), although there have been some inconsistencies.

The authors of this meta-analysis reviewed historic studies to establish whether increased fruit and veg consumption led to a reduction in CHD. This research identified and analysed 23 studies using a total of 937,665 people and 18,047 patients with CHD.

Results showed that increasing fruit and veg intake can lead to significant reductions in CHD risk in Western populations but not in Asian populations. In Western populations the risk of CHD was reduced by 12 percent, providing around 477g a day fruit and veg were consumed, by 16 percent if 300g a day of fruit was consumed and by 18 percent if 400g veg a day was eaten.

Further research is now necessary to equate this into relevant portion sizes and to further investigate the effect of fruit and veg consumption on coronary heart disease in Asian populations.

For more information see: Gan Y et al (2015) International Journal of Cardiology Vol 183 (0) pg129-137. Eggs are a simple and easy way of getting protein and essential micronutrients into the diet. Given this, along with their possible satiety and weight management benefits, it is thought that people with Type 2 diabetes (T2D) could benefit from eating these. New research has now looked into this.

In this randomised controlled trial, researchers recruited overweight or obese people with either prediabetes or Type 2 diabetes (n=140). Each participant was then randomly allocated high-egg (two eggs daily for six days or the week) or low-egg diet (<two eggs per week) for six weeks. Markers of metabolic health were measured in both groups.

Results showed that there were no statistically significant differences in total cholesterol, low-density lipoprotein, triglycerides, or glycaemic control between the groups. However, the high-egg group did report feeling less hungry and having felt fuller after eating breakfast when compared with the low-egg group.

These are interesting findings which imply that high-egg diets could be included safely as part of T2D dietary management. These may also have the added benefit of helping to stave off hunger.

For more information see: Fuller N et al (2015) The American Journal of Clinical Nutrition Vol 101 (4) pg705-13.

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

latEst on VitaMin d

Falls in older people can lead to trauma, hospitalisation, loss of independence and institutionalisation. Existing research into vitamin D status and the likelihood of falls in older people has been inconclusive.

In this study, the authors systematically reviewed previously published work and conducted a meta-analysis to find out whether vitamin D blood serum levels were linked to falls in older people.

The review identified 18 good quality observational studies. Participant numbers ranging from 80 to 2,957 and age ranges between 63 and 84 years.

Results showed that blood serum 25(OH)D levels, a marker of vitamin D status was lower in fallers compared to nonfallers (i.e. tending to be <20ng mL-1). The risk of falls was also lower amongst those with higher serum 25(OH)D levels.

The authors concluded that these findings might help to identify groups that would benefit from taking a vitamin D supplement.

For more information see: Annweiler C and Beauchet O (2015) Journal of Internal Medicine Vol 277 (1) pg16-44.

nEw rEsEarCH on nuts and HEaltH

Eating nuts is known to have beneficial effects on heart health and is thought to reduce the risk of cardiovascular disease. Two new studies have looked into further potential health benefits that might be associated with eating nuts.

A new meta-analysis has looked at whether eating nuts could be associated with decreased mortality. The review identified 15 prospective studies and included a total of 354,933 participants.

Results showed that eating just one serving of nuts per day was found to decrease the risk of all-cause mortality by four percent and CVD mortality by 27 percent. Nut consumption was also associated with a reduced risk of cancer deaths when data from the highest and lower intakes groups were compared.

The authors concluded that nut consumption lowers the risk of death from CVD, although further research is needed to confirm these findings.

A second paper has looked at nut consumption in relation to stroke risk in a German population, forming part of the European Prospective Investigation into the Cancer and Nutrition Potsdam Study.

The study took place over 8.3 years (n=26,285), with details on nut consumption being collected at baseline using a semi-quantitative food frequency questionnaire.

Results showed that the average nut intake was 0.82g per day. While an increased risk of stroke was noted in participants who never ate nuts, no other associations were found.

Overall, findings looking into nut consumption and health are somewhat mixed. Lack of findings may be attributed to the epidemiologyical nature of these studies. More RCTs are needed in order to reach firmer conclusions.

For more information see: Grosso G et al (2015) The American Journal of Clinical Nutrition Vol 101 (4) p783-793 and di Giuseppe R et al (2015) The European Journal of Clinical Nutrition Vol. 69 (4) pg431-435.

tHE nEw Pro-Cal shot®

The new Pro-Cal shot® 120ml plastic bottle has the benefits of being easy to transport, convenient to use with less wastage and is now available in strawberry and neutral flavours with banana flavour coming in July 2015.

For more information or to request a starter pack please visit www.vitaflo.co.uk, contact your local Vitaflo representative or call the nutritional helpline on 0151 702 4937.

PIP Codes: 6 x 120ml strawberry flavour: 394-3891; 6 x 120ml neutral flavour: 394-3909; 6 x 120ml banana flavour: 394-3917

To book your company’s product news for the July 2015 issue of NHD Magazine call 0845 450 2125

wEaning MEtHods and satiEtY

Weaning can be a difficult time with plenty of confusion over which method to use and what foods to provide. Now, new research has looked into how different approaches can affect satiety.

A sample of 298 mums completed a questionnaire when their baby was aged six to 12 months and 18 to 24 months providing information about weaning style, timing of solid foods, child eating style and reported weight.

If was found that infants fed using the babyled approach were significantly more responsive to satiety and less likely to be overweight when compared to those weaned using standard approaches.

These are interesting findings, but additional studies are now needed in the form of randomised trials.

For more information see: Brown A and Lee MD (2015) Pediatr Obes, 10(1), pg57-66.

AD SPACE

enterAl feeding following Stroke

Marion Ireland Specialist dietitian, Stroke rehabilitation, nhS lothian & nhS forth valley

Shubha Moses Specialist dietitian, Stroke rehabilitation, nhS lothian & nhS forth valley

Both marion and Shubha have a longstanding interest in all aspects of neurorehabilitation and have worked in the field for over10 years.

stroke is a major cause of morbidity and mortality in the uk and the third major cause of death accounting for 11% (1). Most people survive a first stroke, but are often left with significant morbidity and/or physical or cognitive deficits.

MAlnutrItIon followIng Stroke Estimates vary from six to 60 percent of patients showing signs of malnutrition following stroke, variance depending on the criteria used to identify malnutrition (2). It is well recognised that malnutrition is an independent risk factor for increased morbidity, poorer outcomes and mortality after a stroke (3-6).

The risk of malnutrition in stroke patients varies, but it is recognised that nutritional status can worsen during admission and that undernutrition following admission is associated with increased case fatality and poor functional status at six months (7). It is important to assess beyond swallowing problems and poor intake and look thoroughly at the mechanics of ‘plate to mouth’ and the entire meal process, to ensure that the impact of any residual deficits is minimised.

nutrItIonAl ScreenIng Screening of all patients should ideally be carried out within 48 hours of admission to hospital (8) and repeated regularly throughout the episode of care. It should also direct referral to a dietitian for assessment and management of nutritional risk.

Malnutrition occurs in approximately 15 percent of all patients admitted to hospital, increasing to approximately 30 percent within the first week. It carries with it a strong association with poorer functional outcome and slower rate of recovery (9).

In addition, SIGN 78 (10) recommends that a nutritional screening tool for use in stroke patients should focus on the effects of stroke on nutritional status, e.g. presence of dysphagia and ability to eat, rather than solely focusing on pre-existing nutritional status.

nutrItIonAl ASSeSSMent And requIreMentS It is unclear to what extent hypermetabolism and hypercatabolism occur post-stroke, with estimations for the increase in metabolic rate following stroke ranging from 10 percent up to 50 percent, (11) depending on the severity and clinical consequences of the stroke, and clinical judgement is required when estimating the increase in resting energy expenditure.

Catabolic effects vary according to the individual, but usually persist for the first few weeks, then begin to resolve in the following weeks and months. Nutritional assessment and estimation of requirements commonly are based on predictive equations such as Henry (2005) (12).

MAnAgeMent of dySPhAgIA followIng Stroke: Dysphagia, is a common and clinically significant complication following stroke (6) which can result in aspiration. The presence of aspiration is associated with an increased risk of developing an aspiration pneumonia and other broncho-pulmonary infections (3).

Both NICE 2004 and SIGN 78 recommend that, following acute stroke, all patients should be screened for dysphagia by an appropriately trained healthcare professional before being given food, drink or medication.

NICE 2008 (14) recommends that, if the admission screen indicates a swallowing problem, then a specialist assessment should take place within 72 hours of admission.

Effective management of dysphagia is of key importance following stroke, in order to prevent undernutrition and dehydration from occurring, as far as possible. This must involve multidisciplinary working and good communication between involved practitioners. Once a full assessment of dysphagia by a speech and language therapist has taken place, the appropriate route of feeding can be identified, making it more attainable to meet nutrition and hydration requirements.

The route of feeding initially is often a combination of oral and enteral feeding, and the management of each transition through the different stages of this spectrum is a crucial part of effective dysphagia management.

enterAl nutrItIon Nutritional intervention following stroke can often involve enteral feeding in patients who are unable to meet their requirements safely or consistently via oral diet and fluids, and for some patients, oral intake is contraindicated completely.

Contraindications to enteral nutrition are patient refusal, patients with a non-functioning GI tract and where it is inappropriate to feed for ethical reasons (16). Enteral feeding in stroke tends to focus on nasogastric and gastrostomy feeding, both of which are used in patients unable to meet their requirements, or who are at risk of diseaserelated malnutrition.

ethIcAl conSIderAtIonS In enterAlly fed PAtIentS The complexities of enteral feeding and insertion of enteral feeding tubes should lead us to concentrate more closely on the decision to feed in the first instance and the ethical considerations surrounding the initiation of feeding in stroke patients as an intervention. However, particularly in this patient group, this is a complex and multifactorial decision, as many of the functional measures that are initially impaired can improve, but at very different rates in each individual, thus making it hard to predict how each patient will progress Each patient’s capacity to contribute to this decision needs to be assessed and, if not deemed able to consent, then additional measures should be put in place regarding consent and capacity to do so.

Enteral nutrition is regarded as an aspect of medical treatment and it is recommended that in cases where the benefits of nutrition support are uncertain, a ‘time-limited’ trial should be undertaken (14) Whilst it is important to avoid nutritional status deteriorating in the acute phase of stroke, the decision to feed severely disabled patients, with little prospect of neurological recovery is difficult, and all aspects of survival need to be taken into account. This needs to be a medical decision and any previously expressed wishes, e.g. living will or advanced directive, should be adhered to.

hydrAtIon Fluid intake in stroke patients is of key importance and may need to be supplemented if unable to be met orally, most commonly by subcutaneous or intravenous fluids in the acute phase of treatment. Once an alternative feeding route is established, most likely nasogastric tube in the acute phase, this can serve a dual purpose of providing nutrition and hydration and should be the route of choice for meeting an individual’s requirements until oral intake of food and fluids improves.

Many factors can make risk of dehydration in stroke patients more likely, such as decreased sense of thirst, fear of incontinence, inadequate intake of thickened fluids required to meet requirements, inability to self-feed and communication difficulties, e.g. difficulties in expressing thirst or need for a drink to carers. Again, with good observation of patients at ward level, coupled with robust assessment measures, these risks can be managed, thus decreasing the likelihood of dehydration occurring.

nASogAStrIc (ng) feedIng Tube placement involves a fine-bore NG tube being inserted trans-nasally into the stomach. The tubes are usually between 8.0-10mm French Gauge, made from polyurethane, PVC or silicone. NG feeding is ideal in the acute setting, for patients who require short-term feeding, identified as less than four weeks (17). It can be used longer term if other options such as gastrostomy feeding are contraindicated or not appropriate (18).

The position of the tube should be confirmed by aspiration of stomach contents and checking that the pH of aspirate is <5.5, indicating gastric contents, as per the National Patient Safety Agen-

cy Guidelines from 2005 (19). The position of a NG tube should be confirmed before each use by aspiration of stomach contents, and radiological confirmation should only be used when there is ongoing difficulty in obtaining aspirate, or concern regarding the tube position that cannot be otherwise resolved.

Consent should be obtained for placement of all feeding tubes, and this can prove difficult in stroke patients (and in other neurological conditions) as there may be cognitive impairment and significant communication difficulties, along with confusion and poor understanding, particularly immediately post stroke. Medical staff usually take responsibility for obtaining consent for procedures that are considered invasive, or identifying when patients do not have the capacity to consent, and putting alternative arrangements for procedures to take place, such as per the guidance for consent and capacity from the British Medical Association in England and Wales, or the Adults with Incapacity Act in Scotland.

Results from the FOOD Trial indicated that early enteral feeding, clarified as within seven days, may reduce mortality and that dysphagic stroke patients should be offered enteral feeding via nasogastric tube within the first few days of admission. However, it also identified worse quality of life in patients who are allocated early tube feeding, concluding that early feeding may keep patients alive, but in a severely disabled state when they would otherwise have died (20). The RCP Stroke Guidelines go a step further, indicating that patients should be fed within the first 24 hours, based on the recommendations of the FOOD Trial and the observed reduction in mortality, with further consultation with patient representatives regarding the timing of initiation of feeding for maximum benefit.

nASAl brIdle (nb) tube retAInIng devIceS Nasal bridles are enteral feeding tube retaining devices that are increasing in use in patients who repeatedly displace nasogastric tubes, e.g. in patients who are confused following stroke. The use of NB loop has been shown to have few complications and minimal discomfort for the patients, and in one prospective study, showed a reduction in 30-day gastrostomy mortality, in part due to better selection of patients for gastrostomy, and also that bridle loops allowed patients an average 10 days of nutrition prior to either recovery or gastrostomy placement. (21) The NICE Guideline for management of acute stroke (14) endorses the consideration of using nasal bridle tubes in stroke patients who are unable to tolerate a NG tube.

gAStroStoMy feedIng Gastrostomy feeding is generally used for patients who require longer-term nutritional support, usually identified as more than four weeks (14). Gastrostomy tubes are placed directly into the stomach, either endoscopically, surgically, or radiologically, and each patient should be fully assessed prior to placement to ensure that there are no contraindications to placement, e.g. previous abdominal surgery, and that placement is appropriate.

Previously, a number of studies comparing nasogastric to gastrostomy feeding showed that there was better success in the administration of feed, less interruption to feeding regimen and lower risk of aspiration with gastrostomy feeding. As a result, patients were more consistently hydrated and fed and nutritional status improved and, with it, many of the functional measures associated with poor nutrition, such as increased frequency of infection, increased risk of pressure areas, depression, loss of muscle mass, etc.

However, the FOOD Trial (20) found that there were no clinically significant benefits of gastrostomy feeding compared to nasogastric feeding and also found a reduction in poor outcomes with NG feeding. The recommendation from this was to use NG feeding initially for the first two to three weeks post stroke, unless there was a clear practical reason to use gastrostomy. An additional finding of interest was that the gastrostomy group had a higher rate of pressure sores, which raised the possibility that these patients may move less or be nursed differently.

Poor outcome following gastrostomy insertion, as concluded by the FOOD Trial, must consider that patient selection is a factor, as those requiring gastrostomy are patients with poor nutritional intake and status and the poorest prognosis. This links in with the finding that, although early enteral feeding is recommended and does not cause any harm, this can keep patients alive but in a severely disabled state where they would

otherwise have died, i.e. survival itself does not equate to survival with good outcome.

The commonly used terminology of Percutaneous Endoscopic Gastrostomy (PEG) and Radiologically Inserted Gastrostomy (RIG) refer to the methods of placement, not type of tube. Tubes are more commonly identified as BalloonRetained and Non-Balloon Retained, and the type of tube and method of placement vary depending on the individual, and which method is most suitable. Surgical gastrostomy can be placed in patients who have failed to tolerate both PEG and RIG procedures.

There are various potential complications of gastrostomy tube insertion ranging from minor complications such as cellulitis and localised skin infection, to more major complications such as infectious peritonitis or buried bumper syndrome.

MedIcAtIon AdMInIStrAtIon Administration of medications is often necessary in stroke patients, due to dysphagia or Nil by Mouth status. Careful guidance should be sought regarding method and timing of administration, along with any drug-nutrient interactions with feed products (22, 23). Administering each medication separately and flushing the feeding tube with 10mls water in between each medication is considered to be good practice.

guIdAnce on MonItorIng Monitoring of patients on enteral feeding should be multidisciplinary, depending on the healthcare professionals involved in that individual’s care. Anthropometric and biochemical markers are essential and useful, along with clinical judgement regarding the medical stability of the patient (24, 25)

dISchArge PlAnnIng It is essential that good practice is established in terms of coordination of discharge from hospital for patients on enteral feeding. Training and support for patients, carers and relatives on all aspects of feeding and ongoing tube care is critical, and it is essential that it is delivered in a timely fashion, with information provided in the most suitable medium for each patient and their carers.

references: 1 British Heart Foundation. Coronary Heart Disease Statistics. BHF 2004 2 Foley NC, Martin re, Salter KL, Teasell rw. a review of the relationship between dysphagia and malnutrition following stroke. J rehabil Med 2009; 41: 707-713 3 Dennis M. Poor nutritional status on admission predicts poor outcomes after stroke. Stroke 2003; 34:1450-1456 4 Davis JP, wong aa, Schluter PJ, Henderson rD, O’Sullivan JD and read SJ. Impact of pre-morbid undernutrition on outcome in stroke patients. Stroke 2004; 35: 1930-1934 5 Martineau J, Bauer JD, Isenring ea, Cohen S. Malnutrition determined by the patient-generated subjective global assessment is associated with poor outcomes in acute stroke patients. Clinical Nutrition 2005; 24(6):pp. 1073-1077 6 Yoo SH, Kim JS, Kwon SU, Yun SC, Koh JY and Kang Dw. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients. archives of Neurology 2008; 65: 39-43 7 Dennis et al. FOOD Trial Collaboration: routine oral nutritional supplementation for stroke patients in hospital: a multicentre randomised controlled trial. Lancet 2005. 365:p755-763 8 Nursing & Midwifery Practice Development Unit. Nutrition: assessment and referral in the care of adults in hospital - best practice statement. NMPDU 2002 9 royal College of Physicians. National Clinical Guidelines for Stroke. rCP 2004 10 Scottish Intercollegiate Guidelines Network. Clinical Guideline 78. Management of patients with stroke: Identification and management of dysphagia.

SIGN 2004 11 Finestone et al. Measuring longitudinally the metabolic demands of stroke patients: resting energy expenditure is not elevated. Stroke 2003. 34: p2502-507 12 Henry CJ. Basal metabolic rate studies in humans: measurement and development of new equations. Public Health Nutr 2005; 8(7a):1133-1152 13 Perry L, Love CP. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 2001. 16(1), 7-18 14 National Institute for Health & Clinical excellence. Stroke - Diagnosis and initial management of acute stroke and transient ischaemic attack. Clinical Guideline 68. 2008 15 National Institute for Health and Clinical excellence. Nutrition Support in adults. Clinical Guideline 32. NICe 2006 16 Lennard-Jones Je. ethical and legal aspects of Clinical Hydration and Nutritional Support. a report for the British association for Parenteral and enteral

Nutrition. BaPeN 2000 17 Manual of Dietetic Practice (4th edition) Blackwell Publishing Ltd 2007 18 Mcatear Ca (ed). Current perspectives on enteral nutrition in adults. BaPeN working party report. BaPeN 1999 19 National Patient Safety agency. Patient Safety alert: reducing the harm caused by misplaced nasogastric feeding tubes. 2005 20 Dennis et al. FOOD Trial Collaboration. effect of timing and method of enteral tube feeding for dysphagic stroke patients: a multicentre randomised controlled trial. Lancet 2005. 365, 764-772 21 Johnston rD et al. Outcome of patients fed via a nasogastric tube retained with a bridle loop: Do bridle loops reduce the requirement for percutaneous endoscopic Gastrostomy insertion and 30-day mortality? Proc Nutr Soc 2008. 67 (OCe) e116 22 white r and Bradnam V (2011). Handbook of Drug administration via enteral Feeding Tubes. 2nd edition. Pharmaceutical Press 23 Smyth J (2012). The NewT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. 2nd edition 24 Todorovic and Mickelwright (2011). PeNG - a pocket guide to Clinical Nutrition, 4th edition 25 aSPeN enteral Nutrition Practice recommendations, JPeN (2009); originally published online