uk o. .c BS JO 09 tic 20 te e ie c .d in w S w w
NHDmag.com
Issue 107 August/September 2015
Vitamin D in Pregnancy Cordelia Woodward p13
ISSN 1756-9567 (Print)
Malnutrition and the elderly. . . p17
Anna FitzGibbon Prescribing Support Dietitian
preterm nutrition dysphagia product update communications in dietetics nutrition and chylothorax
dieteticJOBS • web watch • new research
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
from the editor
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.
In recent weeks, you may have noticed how much media coverage there has been around dental disease in children, along with reports on obesity, diabetes and their impact on the NHS. Within recent days, the Scientific Advisory Committee on Nutrition (SACN) published Carbohydrate and Health Report, which included a recommendation to slash sugar intake and offered the opportunity to increase fibre content in the diet. An initiative of a £15m three-year pilot project in England will see up to 250 pharmacists being recruited to GP practices to provide direct patient care and help ease the workload for the GPs. Might this also be an opportunity for dietitians? Prescribing Support Dietitians are not new and have been involved in the effective and appropriate prescribing of ONS, gluten-free items and other nutrition related items; however, we may be able to do more! Anna FitzGibbon tells us about the role of A Prescribing Support Dietitian for care homes. Anna works with the Integrated Response Team and her role focuses on the prevention of malnutrition, the early identification of those at risk and reducing complications. The role also aims to ensure the appropriate use of oral nutritional supplements. Find out more about this in her article. Keeping with a prescribing theme, I welcome Alison Smith back to give us an informative Dysphagia product update. Not only does Alison’s article describes the different types of thickeners it also provides some costings. ‘The key aims of nutritional management for a patient with Chylothorax are to reduce the volume of the chyle leak and to allow closure of it, to prevent malnutrition, and to replenish fluids and electrolytes that are lost.’ Shona
Scott’s article Nutritional management of chylothorax patients covers the role of a low long-chain triglyceride oral diet, as well as enteral and parenteral options for providing nutritional support in Chylothorax. Some of you may be interested in preterm nutrition and in this issue NHD, Kate Harrod-Wild shares with us the key features of the Nutrition guidelines on the neonatal unit. In a good summer with sunshine, many are able to ‘top up’ their vitamin D! Pregnant women are considered to be at risk of low vitamin D status, and the current advice is that all pregnant women take a supplement of 10 micrograms of vitamin D everyday throughout pregnancy and breastfeeding. Cordelia Woodward tells us more in our Cover Story, Vitamin D in Pregnancy. I firmly believe that excellent communication skills are key skills that all healthcare professionals should have. I encourage you to read what Kirsten Whitehead has to say about Communication skills for dietetians. Let us know what your thoughts are on this. I hope that you all enjoy your NHD summer read. You will now have a slightly longer gap before you receive Issue 108, so you may want to think about reading the above SACN report to fill that gap!
NHDmag.com August/September 2015 - Issue 107
3
Contents
13
COVER STORY
Vitamin D in pregnancy 6
News
38 Dysphagia product update
9
Communications in dietetics
45 A day in the life of . . .
Latest industry and product updates
Where are we going?
Considerations and costings
A dietitian down under
17 Malnutrition and the elderly
47 dieteticJOBS
25 Preterm nutrition
49 Events and courses
31 Chylothorax
50 Subscribe to NHD Magazine
36 Web watch
51 The final helping
Prescribing Support Dietitians
Nutrition guidelines on the neonatal unit
Nutritional management of patients
Online resources and updates
Editorial Panel Chris Rudd, Dietetic Advisor Neil Donnelly, Fellow of the BDA Ursula Arens, Writer, Nutrition & Dietetics Dr Carrie Ruxton, Freelance Dietitian Dr Emma Derbyshire, Nutritionist, Health Writer Emma Coates, Senior Paediatric Dietitian Dr Kirsten Whitehead, Assistant Professor in Dietetics Cordelia Woodward, Freelance Dietitian Anna FitzGibbon, Prescribing Support Dietitian Kate Harrod-Wild, Specialist Paediatric Dietitian Shona Scott, Cardiothoracic Dietitian Alison Smith, Prescribing Support Dietitian Claire Riley, Dietitian
4
NHDmag.com August/September 2015 - Issue 107
Latest career opportunities
Upcoming dates for your diary
It’s easy online
The last word from Neil Donnelly
Editor Chris Rudd RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dawson Design Heather Dewhurst Advertisement Sales Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk @NHDmagazine 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.
Co so min on g
With L LGG®
Dairy doesn't need to be out of reach for long
†
Coming soon: Nutramigen with LGG
A new combination of Nutramigen LIPIL with a probiotic The addition of LGG to Nutramigen LIPIL accelerates the acquisition of oral tolerance in infants with cow’s milk allergy (CMA)1‡ Shortened CMA management could lead to potential cost savings1‡ Clinically proven to effectively manage CMA symptoms2,3
PR
NUTR A
NU T
PREPARATION PREPAR PREP ARA INSTRUCTIONS
ESTIMIL L EG
IL IP
GEN PUR MI
INO AM
MIGEN LI RA
L2 PI
MIGEN L I RA
L1 PI
NU T
The only eHF clinically proven to accelerate time to tolerance1 Find out more at www.nutramigen.co.uk
A solution for all your CMA needs 79% of infants are tolerant to cow’s milk after 12 months using Nutramigen with LGG.1 ‡vs an eHF based on casein, rice hydrolysate, soy and amino acid formulas. eHF, extensively hydrolysed formula. LGG® (Lactobacillus rhamnosus GG) is a registered trademark of Valio Ltd, Finland.
†
References: 1. Canani RB et al. J Pediatr 2013;163:771–777. 2. Baldassarre ME et al. J Pediatr 2010;156:397–401. 3. Nermes M et al. Clin Exp Allergy 2010;41:370–77. 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. EU15.549/07–15.
news
Latest on pregnancy micronutrients: new data on iodine status
Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd
Iodine is important for pregnancy as it helps make thyroid hormones needed for growth, metabolism and babies’ brain development. Now, new work has measured the iodine status of pregnant mums in the UK. The SPRINT (Selenium in PRegnancy INTervention) trials recruited a sample of 230 women and took spoturine samples at weeks 12, 20 and 35 of pregnancy. The iodine-to-creatine ratio (a measure of iodine deficiency) was also measured. Mean iodine concentration from all time points was 56.8μg/L and the iodineto-creatinine ratio was 116μg/g, indicat-
ing that women were mildly to moderately iodine deficient in each trimester. Only 3.0% of women took prenatal supplements containing iodine. On the whole, these findings indicate that this group of pregnant women were mildly to moderately iodine deficient at all trimesters, which is concerning. More studies in other populations are now needed.
Vitamin D and anaemia link?
There is heightened awareness about vitamin D deficiency. As this may also come hand in hand with diseases that involve inflammatory processes, it seems likely that anaemia could also follow. New work has looked into this. A large cross-sectional study of 638 healthy American adults measured vita-
min D (25(OH)D) status and anaemia incidence. Results found that black Americans with serum 25(OH)D) levels less than <50nmol/l had an increased likelihood of anaemia with inflammation. Taken together, these results indicate that individuals with darker skin, poor vitamin D status and inflammation are at greatest risk of having anaemia. For more information, see Smith EM et al (2015). British Journal of Nutrition Vol 113, Issue 11, pg 1732-40.
Magnesium & gestational diabetes
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
6
The number of women developing diabetes in pregnancy is on the rise. While conventional treatments are one option, emerging evidence suggests a possible role for magnesium supplements. Seventy pregnant women with diabetes were randomly allocated to take: 250mg magnesium oxide or a placebo for six weeks. Fasting blood samples were taken at baseline and at the end of the intervention. Results showed that fasting plasma glucose levels and serum insulin levels were significantly lower (P ≤ 0.001)
NHDmag.com August/September 2015 - Issue 107
amongst women who took the magnesium, compared with the placebo by the end of the study. Overall, the findings from this trial indicate a possible role for magnesium in the management of gestational diabetes. More work is now needed to better understand how magnesium exerts its actions. For more information, see: Bath SC et al (2015). American Journal of Clinical Nutrition Vol 101 no 6, pg. 1180-7 and Asemi Z et al (2015). American Journal of Clinical Nutrition Vol 102 no 1, pg. 222-29.
news
Progress on protein
Protein has been hot on the agenda at conferences this year. This seems to be down to the growing body of evidence linking its consumption to satiety and weight management benefits. Now, some new papers add to this further. One of the main verdicts from the Protein Summit 2.0 Conference, published in the American Journal of Clinical Nutrition, was that protein dietary guidelines might need to be revisited. The current Recommended Daily Allowance (RDA) for protein is 0.8 grams per kg. However, a growing body of evidence indicates that amounts around twice this could help to promote a healthy body weight, preserve lean body mass and functional ability with age. Another article looking at the benefits of higher protein diets also concluded that about 1.2 and 1.6g protein per kg a day in the form of 25-30 grams of protein per meal led to improvements in appetite, body weight and cardio-metabolic health. These are interesting findings, implying that a revisit of guidelines and the composition of our diets may be needed.
Vitamin D and depression link
As there are vitamin D receptors in the brain, it makes sense that there could be links with brain function and mood. Now, a new Dutch study has looked at this. Amongst a large sample of 2839 adults aged ≥65 years, vitamin D (25(OH)D) status was measured and depression measured using a validated scale. Genes affecting vitamin-D status were also studied. Results showed that individuals with a higher vitamin D status, i.e. in the second, third or fourth quartiles, had a 22%, 21% and 18% lower score of depressive symptoms compared with those with lower vitamin D status, i.e. in the first quartile. These are interesting findings, indicating that low vitamin D status could contribute to depression. Genetic make-up did not affect vitamin D status in this study. Further studies, including randomised trials are now needed. For more information, see Brouwer-Brolsma EM et al (2015). European Journal of Nutrition [Epub ahead of print].
Product / Industry news
Monogen - nutritionally complete
Monogen is a nutritionally complete, low fat, powdered feed low in LCT and high in MCT. Monogen is intended for use in the dietary management of defects of long-chain fatty acid oxidation and may also be suitable for infants and children requiring a very low fat diet such as seen in Chylothorax, Intestinal Lymphangiectasia and Hyperlipoproteinaemia Type I. Next generation Monogen contains essential fatty acids and is supplemented with DHA. Visit http://nutricia.co.uk/products/view/fatty_acid_oxidation_disorders/monogen
Nestlé Nutrition Institute Satellite Symposium at BSACI September 2015
Are you interested in increasing the awareness of Cows’ Milk Allergy (CMA)? If so please visit us on Stand 20 at the British Society for Allergy and Clinical Immunology (BSACI) Meeting, Telford, 4-6 September. We will be sponsoring a satellite symposium on CMA. Topics include: • “Cows’ Milk Protein Allergy: Improving Standards of Care in Paediatric Practice” • “What do we know about lactose?” • “Introducing the new Cows’ Milk Symptom Score (CoMiSS)” For more details please contact your local representative. For information on our Allergy product portfolio please visit: www.nestlehealthscience.co.uk
To book your company’s product news for the October 2015 issue of NHD Magazine call 0845 450 2125 (local rate)
NHDmag.com August/September 2015 - Issue 107
7
Now Availab le
AN I N
IN PRET�� NUTRI��O M � NOVA TI O N
TH E F
IRST FOR U AND ONLY PROT SE WIT EIN S HF OR PR ORTIFIED B UPPLEMEN E TE R M REAS T T MIL FORM K ULA
nutriprem
protein supplement
for the dietary management of extremely low birthweight infants who require additional protein HOSPITAL USE must be used under medical supervision 98945-1
For use in combination with fortified breastmilk or preterm formula Developed to help meet protein requirements for extremely low birthweight infants
50 x 1g sachets
For the dietary management of extremely low birthweight infants Designed specifically to help meet increased protein requirements, as recommended by ESPGHAN, for infants <1,000g1
mplete o c t s o The m rm range prete lable avai
Adaptable dose to help meet the needs of each extremely low birthweight infant
Practical advice for healthcare professionals from
Important notice Cow & Gate Nutriprem Protein Supplement is a food for special medical purposes for the dietary management of extremely low birthweight infants who require additional protein. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. For enteral use only. Reference 1. Agostoni C et al. Enteral nutrient supply for preterm infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 2010;50(1):85-91.
Communication Skills in dietetics
Communication skills for dietitians: where are we up to and where are we going?
Dr Kirsten Whitehead Assistant Professor in Dietetics, University of Nottingham
For article references please visit info@ networkhealth group.co.uk
Kirsten Whitehead worked in the NHS for over 20 years, moving into dietetic education in 2001. Kirsten teaches communication skills and undertakes research in this important subject area for dietitians.
There are few dietitians who do not agree that good communication skills are at the heart of dietetic practice1,but what exactly is meant by ‘good communication skills’ and how do we know if we have got them or not? This article will discuss some of the recent relevant policy and published literature in this subject area and aims to provide some suggestions for how we could further develop these skills as a profession. The expected capabilities of a graduate dietitian in relation to communication skills are clearly described2, 3. This includes being an effective communicator, active listening, establishing rapport with patients, demonstrating compassion, empathy and understanding. These capabilities are comparable to expectations for healthcare professionals more generally4, 5, 6 and training of healthcare professionals in communications skills to deliver patient-centred care and to support behaviour change is consistently recommended7, 8. Sadly, some healthcare professionals lack skills in communication-related areas, such as demonstrating compassion, offering reassurance and involving patients in care decisions9. To support the NHS in the future, the need for patient-centred care, working with patients and carers to set and achieve healthcare goals by engaging, empowering and listening to the views of patients and carers has been strongly re-emphasised10. The same key messages are consistently being delivered, i.e. good communication skills are important in patient care, a patient-centred approach is required and effective training for those working in healthcare is recommended. What impact do communication skills have on dietetic practice?
In dietetics there is a developing evidence base that supports the positive effects of good communication skills.
One of the key areas is with the demonstration of empathy, that is, the desire to understand the patient’s experience and to demonstrate that understanding to the patient11. Demonstrating empathy in dietetic consultations has been shown to improve patient satisfaction12, 13, 14. Goodchild et al found that the more empathetic the dietitians’ response to emotional cues was, the more satisfied patients were. Greater patient satisfaction is important as it is more likely that highly satisfied patients will maintain appointments and adhere to the dietary recommendations that have been made, which is essential if dietetic practice is going to be effective14. Empathy has also been shown to lead to higher levels of agreement about the decisions made within a consultation12, 15 and to more extensive dietary changes being implemented16. However, there is little evidence as yet to suggest that this leads to improved clinical outcomes16. Several studies have elicited the views of dietitians and their patients on what was desirable within consultations17, 18, 19 . Although these studies were completed in different countries; the UK18, Australia17 and Israel19 and there may be different cultural views, the conclusions were very similar. Patients stated that they want to be treated as individuals17, to be listened to17, to have a rapport with the dietitian17, 18. They wanted a positive partnership17 and for the dietitian to be patient-centred18 and empathic19. Although the clinical skills of
NHDmag.com August/September 2015 - Issue 107
9
Communication Skills in dietetics the dietitian were considered important, patients also valued active engagement, sharing and open communication18 and the appropriate personal presentation of the dietitian17, 18, i.e. smart but not too formal. The ability of dietitians to be flexible in their communication approach was important as some patients prefer a more practitioner-led and some a more patient-led consultation18, 19. In contrast, patients were less likely to attend follow-up consultations when the dietitian lacked a patient-centred approach, lacked empathy, did not individualise advice or focused on information giving19. This reinforces the need for good communication skills for effective practice. One area where there is clear evidence of a need for improvement is in relation to shared decision making. In a Canadian study, Vaillancourt et al used a validated tool to assess dietitians’ consultations and found an overall mean score of 29 (±8.0%) (range 0% [no patient involvement in the decision] to 100% [high patient involvement]) which suggests that dietitians were not involving patients in the diet-related decision making process20. Developing communication skills postregistration
The dietetic workforce includes people who trained in a variety of Higher Education Institutes (HEIs) with differing methods of teaching and learning. The pre-registration training of dietitians is constantly developing and those who trained many years ago will have had a different pre-registration education experience to those who trained more recently. Several studies have demonstrated that dietitians would like more training in communication skills post-registration and that their pre-registration training focused more on knowledge than communication skills1, 14, 21, 22, 23 . There is an assumption that experience leads to skill development, but little evidence to support this. In the UK, there is little to guide dietitians on how to develop their communication skills, or what they should be aiming for. In the USA, the Academy of Nutrition and Dietetics has recently produced a series of documents for a variety of specialist areas of dietetics which define the skills required at three different levels of practice: competent, proficient and expert24. A competent practitioner is recently qualified, a proficient 10
NHDmag.com August/September 2015 - Issue 107
practitioner is generally three or more years postregistration and an expert practitioner is recognised within the professional as having reached the highest level of knowledge and skill. This gives dietitians a very explicit guide to what they need to do to progress in a specific clinical area, and communication skills are included as one of the six domains of professional practice within this24. Similarly, a study undertaken to describe what is meant by advanced or expert practice concluded that advanced practice tasks are patient-centred and include the use of advanced interviewing, education and counselling strategies25. How do dietitians develop from competent to proficient and expert levels in relation to their communication skills? There are many opportunities for Continuous Professional Development (CPD) in communication skills available and some are dietetic specific. Whitehead et al (2009) found that the majority of dietitians responding to a survey (n=906, 79.6%) had undertaken CPD and were very positive about its effect on their work practice, but many were keen to develop their skills further, in particular, in advanced skills such as motivational interviewing and cognitive behavioural strategies1. Evidence from medicine and nursing suggests that communication skills can be enhanced by training; however, there are concerns about the difficulties of transfer of training into practice26, 27 which was also a concern of dietitians1. How do we measure skills?
One of the challenges with skill development is having an objective way of assessing skills. How do we know if attending training actually leads to positive changes in practice? Most studies have explored dietitians’ perceptions of their skills, or patients’ views of the dietitian’s skills, rather than any objective measure. For this reason, Whitehead et al (2014) developed and validated an assessment tool, DIET-COMMS, which is designed for the assessment of communication skills within dietetic patient consultations28. The tool was tested using videoed consultations with simulated patients, with students at various levels of training and qualified dietitians. DIET-COMMS is a simple form covering one side of A4 which consists of 20 items which cover the content of a dietetic consultation and the communication skills within
Communication Skills in dietetics that. Each item can be scored with 0 (not done or not achieved), 1 (partly achieved or attempted), or 2 (fully achieved). DIET-COMMS has been comprehensively tested and it has been found to have face validity, content validity, construct validity, predictive validity, intra-rater reliability and moderate inter-rater reliability. As with any assessment tool, there is a need for those using it to be familiar with it and to be able to assess in a consistent manner. For this reason a training package is being developed to support its use in both student training and for CPD. The training package will be open access via a web page, so no cost will be incurred for users and they will be able to return to the package as often as they wish. The package includes video-recorded mock consultations to a variety of standards. These were undertaken in out-patient clinics, a ward setting and a home setting. There are service user views on the consultations to aid understanding on how the patient might feel or react in those situations and also an expert view on how each consultation would be scored on DIET-COMMS. There are downloadable resources to support teaching and learning. For example, feedback sheets on each of the 20 items on DIET-COMMS are designed to support individuals to identify what they could do differently to improve that specific item. Guidance sheets have been developed, for example, on how to set up peer assessment in the workplace and on giving constructive feedback. The DIET-COMMS training package will be launched in 2015. The way forward
There appears to be a willingness and desire within many dietitians1 to undertake CPD in relation to their communication skills post-registration. The DIET-COMMS training package may support this, but there are other questions to consider. How good are dietitians as a profession at the moment? Some may consider that there is no need for improvement, as dietitians are all good at communicating already. The reality is that we really donâ&#x20AC;&#x2122;t know the answer to this question as the research has not been completed; however, many studies suggest that there is room for improvement1, 18, 19 and considerable variation has been demonstrated28.
Should UK dietitians develop a framework for skills required for competent, proficient and expert levels in relation to communication skills, as has been completed in the USA24? Would such a tool be helpful and would it ensure that this aspect of professional practice would be considered more formally? Should peer observation or peer assessment in the workplace be undertaken routinely? There is evidence that this is occurring in some departments already1, but concerns have been raised that some dietitians would find this threatening and that it would not be acceptable28. However, this already happens with some other healthcare professionals regularly, such as doctors. Is it time for a more consistent approach to dietetic pre-registration training? This already happens in UK medical schools where a national group develops guidance and tools to support the HEIs29. Is there a need for a BDA Specialist Group on communication skills? It is a subject relevant to all, but may provide support and guidance for those who want to develop their skills. There are many unanswered questions and a lot of potential for research which can take the dietetic profession forward. Developments in this area could help dietitians to consistently deliver the high quality, patient-centred, effective services that we are capable of and which are required to meet professional standards and current guidance. What part can you play? NHDmag.com August/September 2015 - Issue 107
11
8KVCƔQ - here tQ help yQW Cnd yQWT RCVKGPVU with PKU ever[ UVGR QH Vhe way. ®
%QPVCEV yQWT reprGUGPVCVKve tQFay tQ NGCTP mQrG CDQWV QWT PKU prQFWEV LQWTney. www XKVCHTKGnFU2-7 EQ WM
#WIWUV 0*&
A Nestlé Health Science Company ® Reg. trademarks of Société des Produits Nestlé S.A Tel: 0151 709 9020 Email: vitaflo@vitaflo.co.uk Web: www.vitaflo.co.uk
cover story
Vitamin D in Pregnancy
Cordelia Woodward BSc RD Freelance Dietitian
For article references please visit info@ networkhealth group.co.uk
Cordelia is a freelance dietitian and owner of www. cwdietetics.co.uk. She has worked previously for NHS trusts as a specialist dietitian and has keen interests in pregnancy, diabetes, weight loss and cardiovascular disease.
Pregnant women are considered to be at risk of low vitamin D levels amongst other subgroups4. There is a close link between a motherâ&#x20AC;&#x2122;s vitamin D level during pregnancy and a new born babyâ&#x20AC;&#x2122;s vitamin D status5. The mother needs to ensure adequate stores for herself and her baby. Adequate stores of vitamin D in pregnan- Figure 1: Adapted from (3). 25(OH)D - 25cy can help prevent rickets in babies and in hydroxy vitamin D; this is used to assess infancy (especially for exclusively breast- vitamin D status, 1,25(OH)2D - 1 25fed babies)1. Although we may think of dihydroxy vitamin D - this is the active form of vitamin D. rickets as a problem from the past, there is concern that it is re-emerging in children Sunlight in the UK6. In addition, alUltraviolet B though not conclusive, some SKIN studies have shown vitamin 7-dehydrocholesterol D deficiency may be associated with an increased risk Previtamin D3 of gestational diabetes, preeclampsia, low birth weight and caesarean section7. Vitamin D3
Vitamin D: background
Vitamin D is a fat soluble vitamin which plays several important roles within the body. One of its key roles is to help absorb calcium and phosphate and, in doing so, it helps to keep our bones strong and healthy. Whilst we get some vitamin D from dietary sources, we make most of it through the action of sunlight on our skin through a series of reactions (Figure 1). Plasma 25(OH)D (also known as 25-hydroxy vitamin D) concentration is used to assess vitamin D status1. In the UK, we can
Circulation
Vitamin D2 and D3 (from diet or supplements)
LIVER 2H(OH)D
Circulation
KIDNEY 1,25(OH)2D
NHDmag.com August/September 2015 - Issue 107
13
vitamin D
The NICE guidelines advise that UK healthcare professionals should recommend a vitamin D supplement of 10 micrograms for all pregnant and breastfeeding mothers only make vitamin D between April and October (the sunlight is only at the correct wavelength in the summer months) and the latest National Diet and Nutrition Survey (NDNS) highlighted that the UK population has lower levels during the winter months2. During winter months the body’s stores of vitamin D from the summer and dietary sources are needed to maintain adequate vitamin D status. Requirements
In 1991, the Committee on Medical Aspects of Food and Nutrition Policy (COMA) set a Reference Nutrient Intake (RNI) of 10 micrograms of vitamin D per day for all pregnant and breastfeeding women (COMA, 1991)8. The Scientific Advisory Committee on Nutrition (SACN) reiterated the above recommendation in 2007 in their update of vitamin D1. This is in contrast to most children and adults, for which there is actually no RNI set, as it is assumed they will get enough vitamin D from sunlight exposure5. This is, however, currently being reviewed by SACN. Supplementation
The NICE guidelines advise that UK healthcare professionals should recommend a vitamin D supplement of 10 micrograms for all pregnant and breastfeeding mothers9. This is also supported by the Royal College of Obstetricians and Gynaecologists7. All pregnant women should be informed about the importance of vitamin D supplementation at their first appointment with their healthcare professional5. Some women are at greater risk of vitamin D deficiency, including those with darker skin and women with limited exposure to sunlight and so extra care must be taken to ensure that these women are taking a daily vitamin D supplement9. 14
NHDmag.com August/September 2015 - Issue 107
Whilst the advice for vitamin D supplementation is not new, evidence suggests that it is not necessarily being implemented as well as intended. To highlight this, the Infant Feeding Survey10 suggested that the majority of women do not take vitamin D supplements during pregnancy. Vitamin D supplements can be obtained from a pharmacy, a supermarket, or on prescription. They are also included in ‘Healthy Start vitamins’ (eligible for some women) and ‘pregnancy multivitamins.’ Although most commercial multivitamins are likely to contain vitamin D, these are best avoided in pregnancy due to their vitamin A content (which can harm the unborn baby). Vegan pregnant women should ensure that their vitamin D supplement is not from an animal origin by checking the label. Where to get Healthy Start vitamins from: • Health clinics • Children’s Centres • Sure Start Centres • Outreach programmes • GP surgeries
Food Sources
Sunlight is the main source of vitamin D and food sources are limited. For most people, diet only provides 10-20% of total vitamin D intake with 80-90% coming from cutaneous synthesis following sunlight exposure11. The main sources are shown in Table 2. Cooking methods can impact the vitamin D content of a food; for example, baking fish has no effect, whereas fry-
vitamin d
Whilst oily fish is a good source of vitamin D, it must be noted that pregnant women are advised by the government to limit oily fish to twice per week due to pollutants in the fish.
Table 2: Sources of vitamin D in the diet (data obtained from Dietplan7, Forestfield Software). μg - micrograms Vitamin D (μg) Per 100g Salmon, fresh, wild
8.60
Salmon, fresh, farmed
4.70
Canned salmon, pink, drained
1.60
Smoked salmon
8.90
Tuna, raw
3.20
Tuna, canned
1.10
Pilchards, canned in tomato sauce
14.00
Mackerel, raw
8.00
Sardines, canned in oil, drained
3.60
Eggs, whole, raw
3.20
Eggs, yolk, raw
12.80
Eggs, white, raw
Nil
Beef, mince, raw
0.70
Fortified breakfast cereals
3.00-8.4
Fortified fromage frais
1.25
Fortified yoghurt
4.00
Fortified fat spreads
5.00-7.5
Fortified dairy free milk alternative drinks
0.75-0.8
week) due to the mercury content. Moreover, eggs, another source of vitamin D, need to be thoroughly cooked to prevent the risk of salmonella. Cod liver oil (5μg vitamin D per capsule) and liver (1.1μg/100g) should also be avoided completely during pregnancy due to their high vitamin A content13. High street food retailer Marks & Spencer have recently added vitamin D to their bread and bread rolls, with a minimum of 0.75 micrograms per 100g. It will be interesting to see if other food retailers do likewise. Can too much vitamin D be harmful?
ing fish reduces the content by 50%12. Whilst oily fish is a good source of vitamin D, it must be noted that pregnant women are advised by the government to limit oily fish to twice per week due to pollutants in the fish. The advice is also to limit tuna to no more than four cans per week (or no more than two tuna steaks per
In the UK, the Expert Group on Vitamins and Minerals reports that taking 25 micrograms or less a day of vitamin D supplements is unlikely to cause any harm14. Our body does not make too much vitamin D through sunlight; however, individuals need to be aware of sun safety and should cover up/protect skin if they are out for long periods4. Assessing vitamin D adequacy
There is much debate regarding the appropriate cut-off values for optimal vitamin D status15; however, the National Osteoporosis Society, in a document entitled Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management, in 201316 proposed the following thresholds for bone health with regard to assessing vitamin D status (using 25-hydroxy vitamin D as a marker): • Less than 30nmol/litre - deficient • Between 30-50nmol/litre - may be inadequate in some people • Greater than 50nmol/litre - sufficient for almost the whole population NHDmag.com August/September 2015 - Issue 107
15
Whilst not at a national level, several studies have demonstrated that pregnant women have low vitamin D status. NICE guidelines5, on the other hand, define deficient as less than 25nmol/litre. Screening pregnant women
Currently, it is not routine for women to be screened for vitamin D deficiency in pregnancy because there is no data to support this in terms of health benefits or cost effectiveness7. Current Intake/Status - NDNS
Results from the NDNS 2014 reported evidence of an increased risk of vitamin D deficiency in all age/sex groups. Almost one fifth of UK adults were found to have a low vitamin D status (in this case, defined as less than 25nmol/litre)2. Whilst not at a national level, several studies have demonstrated that pregnant women have low vitamin D status1. For example, a study by Brough et al (2010) found that 70% of women in their first trimester from a diverse ethnic group in London had 25-hydroxy vitamin D below 50nmol/litre (insufficiency)15.
In addition, a study on 160 women in South Wales found that 50% of women had levels below 20nmol/litre (deficiency) on their first antenatal visit17. Summary
In summary, vitamin D plays an important role in the body, helping to absorb calcium and keep our bones strong and healthy. In pregnancy, having adequate vitamin D can help prevent rickets in babies as well as having other potential benefits. Pregnant women are considered to be at risk of low vitamin D status, as highlighted in several studies, and the current advice is that all pregnant women take a supplement of 10 micrograms of vitamin D everyday throughout pregnancy and breastfeeding. Dietitians have a role to play in educating patients about the importance and reasoning behind such supplementation advice and helping to ensure that it is being implemented.
References 1 Scientific Advisory Committee on Nutrition (2007). Update on Vitamin D. London: TSO. Available at: www.gov.uk/government/uploads/system/uploads/ attachment_data/file/339349/SACN_Update_on_Vitamin_D_2007.pdf [accessed: 18/06/2015] 2 Bates B et al (2014). National Diet and Nutrition Survey. Results from years 1-4 (combined) of the Rolling Programme (2008/2009 - 2011/12), London: Public Health England 3 Zhang and Naughton (2010). Vitamin D in health and disease: Current perspectives. Nutrition Journal 9:65 4 National Health Service (2015). Vitamin D. Available at: www.nhs.uk/Conditions/vitamins-minerals/Pages/Vitamin-D.aspx [accessed 17/06/2015] 5 National Institute of Clinical Excellence (2014). Vitamin D increasing supplement use among at risk groups. Available at: www.nice.org.uk/guidance/ph56/ resources/guidance-vitamind-increasing-supplement-use-among-atrisk-groups-pdf [accessed: 26/04/2015] 6 Pearce SHS & Cheetham TD (2010). Diagnosis and management of vitamin D deficiency. British Medical Journal; 340:1420147 7 Royal College of Obstetricians and Gynaecologists (2014). Vitamin D in Pregnancy. Available at www.rcog.org.uk/globalassets/documents/guidelines/ scientific-impact-papers/vitamin_d_sip43_june14.pdf [accessed 17/06/2015] 8 Committee on Medical Aspects of Food Policy (1991). Report on Health and Social Subjects 41 Dietary Reference Values (DRVs) for Food Energy and Nutrients for the UK, Report of the Panel on DRVs of the Committee on Medical Aspects of Food Policy. The Stationary Office. London 9 National Institute of Clinical Excellence (2008). Antenatal care. Available at: www.nice.org.uk/guidance/cg62/resources/guidance-antenatal-care-pdf [accessed: 18/06/2015] 10 Bolling K et al (2007). Infant Feeding Survey 2005. The Information Centre 11 Food and Health Innovation Service (2012). Fish as a dietary source of healthy long chain n-3 polyunsaturated fatty acids (LC n-3 PUFA) and vitamin D. Available at: www.abdn.ac.uk/rowett/documents/fish_final_june_2012.pdf [accessed: 18/06/2015] 12 Chen TC et al (2007). Factors that influence the cutaneous synthesis and dietary sources of vitamin D. Arch Biochem Biophys; 460:213-7 13 National Health Service (2015). Foods to avoid during pregnancy. Available at: www.nhs.uk/conditions/pregnancy-and-baby/pages/foods-to-avoid-pregnant. aspx#close [accessed: 18/06/2015] 14 Foods Standards Agency (2003). Safe Upper Levels for Vitamins and Minerals, Available at: http://cot.food.gov.uk/sites/default/files/vitmin2003.pdf [accessed: 18/06/2015] 15 Brough L et al (2010). Effect of multiple-micronutrient supplementation on maternal nutrient status, infant birth weight and gestational age at birth in a lowincome, multi-ethnic population. The British Journal of Nutrition 104(3): 437-45 16 National Osteoporosis Society (2013). Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management. Available at: www.nos.org.uk/ document.doc?id=1352 [accessed 17/06/2015] 17 Datta S et al (2002). Vitamin D deficiency in pregnant women from a non-European ethnic minority population - an interventional study. BJOG 109, 905-908
16
NHDmag.com August/September 2015 - Issue 107
Malnutrition and the elderly
A Prescribing Support Dietitian for care homes Prescribing Support Dietitians (PSD) have generally been employed to ensure the clinical and cost-effective prescribing of oral nutritional supplements (ONS) in the community, with the management of nutrition support patients. This role continues to grow to include a variety of settings and focus has extended to gluten-free products, infant formulas and thickeners. Anna FitzGibbon Prescribing Support Dietitian, Care Homes Integrated Response Team
For article references please visit info@ networkhealth group.co.uk
Anna FitzGibbon is a Prescribing Support Dietitian for care homes, employed by First Community Health and Care. Anna has worked as a Dietitian for 15 years, mainly in prescribing support roles. Her main interests (aside from prescribing support) are nutrition in older people and dementia care.
In 2013, I was offered the role of PSD for care homes, working within the Integrated Response Team (IRT) that covers care homes for adults in the northern part of West Sussex. The IRT is made up of nurses, a pharmacist and a dietitian. It is commissioned by Crawley, Horsham and Mid-Sussex Clinical Commissioning Groups (CCGs) to work with those care homes identified as needing support by members of the IRT steering group. The group includes representatives from the CCGs, adult safeguarding team, West Sussex County Council and local GPs. The IRT works in collaboration with care homes to improve awareness of community services and to empower staff through training and education in order to provide consistent evidencebased care. This leads to a reduction of inappropriate and unnecessary 999 calls, A&E attendances and hospital admissions. We also provide general support to all care homes in the area through our care home forums, newsletters and rolling training programme. SUMMARY OF THE DIETETIC ROLE
The Prescribing Support Dietitian role within the IRT aims to raise the standard of nutritional care provided within care homes through advice, training and support to all staff involved in food and fluid provision. The role focuses on the prevention of malnutrition, the early identification of those at risk and reducing complications. The role also aims to ensure the appropriate use of oral nutritional supplements.
Liaison with other healthcare professionals and teams that support care homes guarantees consistent evidencebased messages around the common nutritional concerns and nutritional management of individuals at risk of malnutrition in care homes. For example, involvement in the care home champion meetings for community nurses and presenting at tissue viability nursing team meetings. BACKGROUND
It is known that malnutrition and dehydration in care homes can lead to increased risk of hospitalisation, readmission and long term ill health1. The British Association for Parenteral and Enteral Nutrition (BAPEN) found that over 37% of residents admitted to care homes were either malnourished or at risk1. This highlights the need for excellent nutritional care. However, the Dignity and Nutrition report from CQC showed that one in six homes did not meet the standard set for nutritional care (outcome 5)1. This role provides opportunity to engage with a wide range of stakeholders linked to care homes with the aim of raising the awareness of the importance of recognising malnutrition early, preventing its development and treating the condition appropriately. The emphasis has been around improving nutritional care in care homes, increasing knowledge and confidence in adopting a food first approach for residents who are at risk of malnutrition.
NHDmag.com August/September 2015 - Issue 107
17
I THOUGHT Iâ&#x20AC;&#x2122;D HAVE TO ASK MY SON FOR HELP. STAYING STRONG MEANS HE CAN ASK ME. NEW Ensure Plus Advance. It helps provide the nutritional support they need to get back to what they love.
Ensure Plus Advance Visit abbottnutrition.co.uk to find out more. Date of preparation: September 2014
RXANI140256e
Malnutrition and the elderly Chart 1: Resulting change in ONS prescription following dietetic intervention
Improving residents’ nutritional status through food is the most appropriate way to manage the risk of malnutrition and the associated complications of this. Malnutrition brings the associated costs of an increased number of GP visits, more prescriptions, slower healing, reduced immunity and longer hospital stays which is estimated to cost the UK economy £13 billion per year2. Oral nutritional supplements (ONS) are a common treatment for malnutrition and can be inappropriately prescribed. ONS are often initiated before food fortification and dietary counselling has been trialled, frequently with no assessment or goals of treatment. Food should be a first line treatment3, 4, although lack of knowledge, historical use and inconsistent messages promote care home staff to regard ONS as the ‘magic bullet’ to treat malnutrition. By supporting care homes to provide balanced nutritious menus, providing education on the timely identification and management of malnutrition and to raise awareness of the appropriate use of oral nutritional supplements, (i.e. use of ONS only if meeting Advisory Committee for Borderline Substances (ACBS) criteria after dietary measures have been unsuccessful in achieving goals of treatment), there is a reduction in the number of oral nutritional supplements needed. This approach offers significant cost savings and cost avoidance to the Clinical Commissioning Group(s).
- - - - - -
The IRT Prescribing Support Dietitian: • reduces inappropriate prescribing of oral nutritional supplements through education, training and clinical assessments; • empowers carers to support a residents’ return to a balanced food intake, reducing the need for inappropriate ONS; • empowers carers to use Food First throughout their home, thereby reducing requests for ONS prescriptions; • improves nutritional care as described above, which can: reduce admissions reduce readmissions reduce hospital stay improve quality of life and promote independent living reduce long-term dependence on ONS maximise food intake facilitating longterm recovery and nutritional health2, 5.
KEY COMPONENTS OF THE PSD FOR CARE HOMES ROLE
Dietetic assessments and reviews All residents in the care home who receive a prescription for an oral nutritional supplement are assessed and then reviewed (with GP and, if possible, resident consent) by the IRT dietitian. Exclusions: • Those under the care of another dietitian. In this case, contact is made to inform them of IRT intervention and dietetic aims around ONS and Food First. • Those individuals with enteral feeding tubes in situ. 59 residents were reviewed in eight care homes over a nine-month period (see Chart 1). • 32 residents (54%) assessed did not require further prescription for oral nutritional supplements after dietetic advice, so a request to the GP was made to stop prescriptions. NHDmag.com August/September 2015 - Issue 107
19
Malnutrition and the elderly • 11 residents (19%) had their prescription modified; reduced or product change or increased. • 16 residents (27%) had no changes made to their prescription: - Some patients were end of life or had advanced dementia, so it would have been challenging and distressing to discontinue the prescriptions. Unfortunately prescriptions are often commenced in these groups with good intentions, but inappropriately. Perhaps to be seen to be providing nutritional support or due to challenging behaviour and repeated food refusal. - Some residents did meet ACBS criteria and required ONS to support their nutritional status (such as those with COPD, Parkinson’s and oesophageal stricture). However, education was needed to ensure that Food First was implemented as well as ONS in order to gain the greatest benefit. There is strong evidence to confirm that the majority (78%) of prescribing is inappropriate based on findings of: • 19 residents having MUST scores of 0 (i.e. healthy weight and no significant weight loss). • 42 residents on ONS not meeting the ACBS criteria for prescription. • 13 residents prescribed only one dose daily. • Food First advice consistently not being fully implemented. Findings show that due to the complexities of resident’s clinical condition, family, resident and carer expectations, cultural reliance and lack of knowledge that ONS is consistently used inappropriately. For example; A pudding style supplement was being used as dessert rather than using the menu options available. This was costing the CCG £3.92 per day (two items); a fortified pudding would provide greater calories (fortified mousse provides 308Kcal compared with between 170-200Kcal by standard pudding style ONS) and costs the care home ~£0.38. Ceasing ONS is therefore a challenging process. Dietetic expertise is required to assess residents that may not require ONS, but due to a variety of factors should continue with their prescriptions. Where possible, more cost effective products are recommended, hence the reason that 54% of residents prescribed ONS had the 20
NHDmag.com August/September 2015 - Issue 107
recommendation to stop, not the 78% found to be receiving prescriptions inappropriately. This is where the importance of effective training on the identification and management of malnutrition, particularly around prevention, is vital. This role ensures engagement with the key stakeholders to promote and cascade the preventative and Food First messages, resulting in better nourished residents and fewer requests for ONS. TRAINING
In-house training around identifying and managing malnutrition is provided to those homes identified to the IRT. This is tailored to include case studies and documentation relevant to the home and the staff attending. The majority of staff trained are carers (i.e. not registered nurses). All training is designed to deliver simple take-home messages that can easily be implemented in a care home, e.g. the use of fortified milk for all residents. Evaluation is consistently positive with 98% of attendees rating the training as very good or excellent. A generic nutrition training session is delivered on our rolling training programme. Common concerns encountered during the team’s work have prompted the development of workshops including bladder and bowel (nutritional management of constipation), dysphagia management and ‘MUST’. The importance of good nutrition and Food First messages are included in all the training delivered by the IRT. Resources Listed below are the resources that have been developed to support care home staff to deliver excellent nutritional care: • Nutritional Care: • Food First advice to promote weight • Nourishing drink recipes • Managing Constipation • Using oral nutritional supplements • Diabetes Mellitus and diet • Overview of meals (catering advice) • Core actions and minimum standards for nutrition and hydration • MUST record sheet and actions • Malnutrition assessment • Dignity at mealtimes (advice when assisting individuals to eat and drink)
Malnutrition and the elderly Graph 1 shows the reduction in ONS usage following dietetic intervention in the IRT focus homes
Lower savings achieved in Care Home 3 due to a large number of residents transferred from another home with complex needs and a heavy reliance on ONS. It is very difficult to reduce or cease ONS in end of life or in residents that have become dependent on ONS. Graph 2: Total savings on ONS across 8 IRT focus homes
Key Performance Indicators The dietetic role has three main KPIs attached against which the role is measured and evaluated. KPI 1: Reduce usage of ONS by 50% • On average 18% of residents across the eight homes (all nursing) were prescribed ONS. • Across the eight homes the number of ONS (as items) was reduced by 77%.
• This represents a 59% reduction in spend ONS products. KPI 2: 80% of target care homes are using a validated malnutrition screening tool: • 100% of focus homes are using MUST at the end of IRT intervention. • An audit was carried out by the team to assess nutrition screening, accuracy of the result, NHDmag.com August/September 2015 - Issue 107
21
NE
ESENTAT PR I
120ml
ON
W
bottle
Same great product Improved new look! Available in Strawberry, Neutral & Banana flavours Contact your local Vitaflo® representative today to find out more about the new look to Pro-Cal shot.
A Nestlé Health Science Company ®Reg. Trademark of Société des Produits Nestlé S.A.
Nutritional Helpline: +44 (0)151 702 4937
Web: www.vitafloweb.com
follow us @ProCalNews
Pro-Cal shot is a Food for Special Medical Purposes. NHD0815B July 2015
Malnutrition and the elderly documentation of results and actions if the resident is identified at risk. This local audit highlighted frequent screening, but often scores were inaccurate with little or no evidence of action in the nutrition care plan6. • MUST training is now provided as part of the bespoke training delivered in focus homes and is included on the rolling training programme. KPI 3: Reduce prevalence of malnutrition by 5.0% (from baseline assessment): • National data suggests between 32-42% of older adults in care homes are malnourished7. • This is reliant on care homes screening accurately, which has been found not to be the case locally. • Therefore, baseline data collection includes nutrition screening on 50% of residents undertaken by the team to ensure accuracy of data. • Current data suggests prevalence in line with national reporting. • Care homes have this repeated at the threeto six-month review. • Data collected for one care home at the sixmonth review point suggested a decrease in the prevalence of malnutrition in the region of 6.0% from baseline assessment. COST AVOIDANCE
Dietetic intervention can reduce prevalence of malnutrition and dehydration, which in turn could prevent falls, UTIs, constipation, promote wound healing and prevent the initiation of ONS 5. All of these factors have a significant impact on cost both in terms of quality of life and finance. This cost avoidance is difficult to measure. The possible exception would be avoidance of ONS prescriptions; however, because only those individuals already prescribed ONS are seen, the cost avoidance linked to improved nutrition and thus preventing requests for ONS is difficult to estimate. It is likely that as a result of the education, training and resource that is put into the focus
homes and messages cascaded via the IRT newsletter and through forums and rolling training, that many residents who would have started on ONS did not, because the Food First message had been implemented and those at risk identified earlier, thus preventing deterioration. As part of this role, liaison with the CCG’s GPs, medicines management team and other teams, such as tissue viability nurses, admission avoidance and community nursing also provides opportunity to further promote the Food First message. All nurses within IRT are aware of and promote the Food First message. FUTURE AREAS OF WORK
• Reduce laxative prescriptions: Laxative use is widespread in care homes. There is some evidence demonstrating a reduction in laxative use by introducing fruit smoothies onto the care home menu8. • Reducing inappropriate use of thickeners (e.g. Nutilis, Thick and Easy, ThickenUp): Observations suggest an over use of thickening agents, often after a ‘coughing episode’. This can in fact negatively impact on the hydration status of residents by reducing fluid intake causing dehydration9 and which, in turn, can contribute to falls, delayed wound healing, reduced cognitive function and quality of life. This inappropriate use is again at a cost to the CCG. Training and resources targeting this will aim to positively impact on the malnutrition and dehydration commonly seen in residents with dysphagia. CONCLUSION
A Prescribing Support Dietitian for care homes is proving to be an effective and high quality intervention for improving the nutritional care of residents in care homes and reducing inappropriate prescribing of oral nutritional supplements. The role is far reaching through liaison with other community based teams, GPs and medicines management to promote ‘Food First’. Without the dietetic role, malnutrition in care homes would continue to be under recognised, under treated and inappropriate prescribing of ONS would continue. NHDmag.com August/September 2015 - Issue 107
23
Malnutrition and the elderly Working with care homes Challenges encountered in raising awareness of malnutrition and its management • The assumption that the elderly do lose weight and this is normal. This has been found elsewhere10. • Poor communication between staff - care staff do not routinely read care plans and are not encouraged to inform the plan10. Care staff often know their residents in great detail, but this is not reflected in the documentation. • Poor care planning with generic statements such as ‘to provide Mr X with a balanced and varied diet’; no detail as to what this means to them or how to deliver this. • Food and fluid charts that are poorly completed, therefore, potentially suggesting that residents have not been offered food or drink at certain times of the day. Often staff are not clear as to why a resident is on a food and fluid chart and the charts are never evaluated, further impacting on their completion11. • MUST is a tick box exercise - it often seems not to matter what the MUST score is; there is no difference reflected in the care plans and MUST is simply something that ‘CQC expect to see’6. • Lack of awareness about how to manage ‘challenging behaviour’ in people with dementia. Often this means residents are malnourished and may be prescribed ONS for the sake of doing something. • 80% of people living in care homes have dementia or memory problems12. Some care home staff may not understand how to communicate with or manage those with dementia13. • Residents at end of life are prescribed oral nutritional supplements because the resident is not eating and/or for the sake of doing something. Our solutions • Assumptions and ‘myth busting’ around weight loss, ‘normal’ weight for older persons and use of ONS is always included in nutrition training and all related training. • The importance of good documentation is thread through all IRT training and a workshop (includes care planning, food and fluid charts and screening tools) specific to this topic is now included on the teams rolling training programme. • Basic information and awareness raising around dementia is discussed during training, resources provided and care homes are signposted to the specialist dementia care teams in the area. Key points to remember when working with care homes General • It may be obvious, but remember to work with the care home and consider what is important to them, what the barriers are and what can they change and implement. • Consider who your stakeholders are. It may be obvious to engage with the manager and catering staff, but there may be a member of staff who has a particular interest, works daily and could be your nutrition champion. Other members of staff soon ‘role model’ and your suggestions become part of the daily routine. • Do not assume that your advice ‘to provide homemade fortified milkshakes’ will be carried out. Be specific maybe ask the chef about their ideas, where they can source dried milk powder/egg white powder from, suggest specific amounts to add to different food and drinks. Discuss how this can be implemented, when and by whom? Training • Staff will always benefit from training even if it is a refresher, a reminder on MUST and the benefits of detailed personalised care plans and good documentation. • Keep your key messages SMART - provide only a few specific key messages; you may be able to build upon these if you visit the home regularly. If someone doesn’t understand, it is likely not to be done. • Use the care homes own documentation for examples if possible, e.g. their food and fluid charts. Also, try to use some of the residents as case studies - this relates the training to the home and helps staff engage. • Add in some information about managing some of the behaviours associated with dementia, such as distracted from eating or wanting to walk/restless at mealtimes. The Caroline Walker trust has published an excellent resource which can support you with this. ‘Eating Well: supporting older people and older people with dementia’14. • Several short ‘bite-sized’ training sessions may be better to deliver key messages to staff than trying to deliver one three-hour session. Always encourage the manager and catering staff to attend. • Make any training very interactive. All the training IRT delivers almost 100% of attendees state that their favourite part is the discussion, games or practicals. • One size does not fit all - focus on the areas that can be improved in that particular home, even if it is just one thing. • Do not get frustrated! Sometimes the care home is not in the ‘right place’ - it may be a better use of your time to postpone intervention until the new manager is in place, for example.
24
NHDmag.com August/September 2015 - Issue 107
Preterm nutrition
Nutrition guidelines on the neonatal unit There has been an increased emphasis on standardised feeding regimes in neonatal units in recent years. Although there is still much research needed on optimal feeding regimes, standardised feeding regimes have been found to reduce rates of necrotising enterocolitis (NEC), a potentially devastating complication of prematurity which can lead to gut necrosis, gut resections and even death. Kate Harrod-Wild Specialist Paediatric Dietitian, Betsi Cadwaladr University Health Board
Kate Harrod-Wild is a Paediatric Dietitian with almost 25 years’ experience of working with children in acute and community settings. Kate has also written and spoken extensively on child nutrition.
Where standardised feeding regimes have been introduced, NEC rates have reduced and NEC has been virtually eliminated in some centres1. As a result, neonatal networks have worked to develop enteral feeding guidelines to use across their networks, the most well-known of which is the East of England Network guideline2. The Welsh Neonatal Network - which I work within - has recently finished an enteral feeding guideline for our preterm infants, which is based on this guideline. This launched in October 2014 at the Wales Neonatal Network Audit Day and Wales Health Boards are now working on implementation. A key factor is ownership and some of the lessons we have learned are the following: 1. It is helpful to have a well-respected consultant to champion the guidelines. 2. The support of the Network is key. 3. Involvement from the multidisciplinary team makes implementation more successful. 4. A clear process for implementation is needed from management downwards. We: a. made presentations at different forums from the Network Audit Day to a Dietetic Managers’ meeting; b. developed and piloted a pathway on two units; c. held a champions’ study day where we presented the process used to produce the guideline, the guideline itself, a version of the pathway and led a discussion on implementation.
The Guidelines are to be used in their original form across the Network, but health boards are adapting the pathway to fit local circumstances. Some of the key features of the guideline are discussed below. Nutritional requirements
The nutritional requirements of preterm infants are higher than for infants born at term and the reasons are multifactorial: • Low nutritional reserves/stores. • Immature organ systems - leading to increased work of breathing and reduced digestion and absorption of nutrients, for instance. • Increased risk of infection (due to immature immune system). Care on the neonatal unit is designed to minimise the impact of these deficits; for instance, ventilation supports immature lungs where necessary and babies are nursed in incubators or hot cots to minimise the heat loss from immature skin. However, comparison of nutritional requirements (see Table 1), demonstrates that, despite these measures, nutritional requirements are significantly higher in preterm infants relative to size, with additional difficulties in meeting these requirements. Embleton et al6 established that preterm infants accrue an inevitable protein deficit that is strongly correlated with postnatal growth retardation on the neonatal unit. Poor growth velocity in preterm neonates has been related to risk of cerebral palsy, subnormal mental development
NHDmag.com August/September 2015 - Issue 107
25
Some babies are crying out for Similac Alimentum It’s got proven acceptability,1 and because 93% of the peptides are <1,000 Daltons in size, it’s got hypoallergenicity all wrapped up too.2 So if a baby has an allergy to cow’s milk, don’t compromise, choose Similac Alimentum. For more information, visit abbottnutrition.co.uk
Important notice: Breastfeeding is best for babies, and is recommended for as long as possible during infancy. Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional. References 1. Data on file. Abbott Laboratories Ltd., 2013 (AK94: Tolerance and compliance of infants fed an extensively hydrolysed infant formula). 2. Sampson HA et al. J Pediatr 1991;118(4):520-525. Date of preparation March 2014 RXANI140054.
Therefore, trophic feeding (up to 24mls/kg/d) is increasingly standard practice on neonatal units; giving small amounts of feed enterally to keep the gut patent while building up parenteral feeds, until the infant is stable enough to increase enteral feeds. A recent large prospective study10 found that early introduction of enteral feeds in growthrestricted preterm infants, results in earlier achievement of full enteral feeding and does not appear to increase the risk of NEC. However, concerns regarding the risk of NEC mean that any change in practice around early feeding is likely to be viewed very conservatively. A new large multi-centred trial in the UK and Ireland undertaken by SIFT group (Speed Increasing Feeds Trial) aims to recruit 2500 very preterm or VLBW infants to compare advancement of feeds at either 30ml/kg/day or 18ml/kg/day. This trial will recruit infants who are fed either human or formula milk. Initial results are awaited. Breast milk
index and neurodevelopmental impairment7. Neurological examination performed at 5.4 years by a neurologist blinded to perinatal outcome, found cognitive deficits were associated with intrauterine growth retardation (measured as weight at birth), poor neonatal weight gain and lower postdischarge head circumference8. Improved protein and energy intakes in just the first week were associated with improved neurodevelopmental scores at 18 months9. Time taken to stabilise respiratory status, delays in starting and increasing parenteral and enteral feeds and episodes of sepsis leading to feeds being stopped, all contribute to deficits in nutritional status for preterm babies while on neonatal units. Most infants under <1500g will not tolerate full nutritional requirements enterally from day 1 and will need parenteral nutrition; this too will take several days to meet the infantâ&#x20AC;&#x2122;s full nutritional requirements. The immaturity of the preterm gut means that enteral feeds need to be advanced cautiously. However, it is important that enteral feeds are introduced as early as possible to prevent gut atrophy, leading to an increased risk of infection via the gut. However, advancing enteral feeds too fast risks NEC. 28
NHDmag.com August/September 2015 - Issue 107
Use of breast milk has been well recognised to decrease the risk of NEC. Prospective, longitudinal nutritional studies in preterm infants started in the 1980s11, evaluating the influence of early dietary practices on clinical and neurodevelopmental outcomes. In these early studies, any breast milk (MEBM or donor breast milk (DBM)) was shown to reduce the incidence of NEC by up to tenfold12. The protective effects of breast milk have been correlated with its anti-inflammatory components (IL-10), growth factors (EGF), erythropoietin, lysozymes and immunoglobulins, as well as pre- and probiotics which favourably affect gut microflora13. Mothers should be given all necessary support to start expressing breast milk within a few hours of birth and encouraged to express at least eight times a day including at night. Techniques, such as â&#x20AC;&#x2DC;hands-onâ&#x20AC;&#x2122; pump expression, can help to maximise volumes and suitably trained midwives and neonatal nurses should provide ongoing support to ensure volumes are maintained and breasts are emptied so that the calorie rich hind milk is expressed. Breast milk from the mothers of preterm infants is known to be higher in protein than the milk of term infants, helping to provide the necessary extra protein intake (Table 2); although, after the first
Preterm nutrition few weeks, protein levels start to fall towards term levels. Where MEBM is not available, donor breast milk is thought to be helpful in reducing the risk of NEC in high risk infants (<28 weeks; <1000g; IUGR). However, this milk is often drip milk so called because it drips from one breast while the baby feeds from the other. As a result, donor breast milk can be much lower in calories and protein than standard breast milk, which has adverse consequences for growth. More recently, preterm donor milk has become available from some milk banks, which should be used whenever possible. In addition, some breast milk banks are making nutritional analyses of their donor milk available, which makes it easier to assess the nutritional adequacy of the milk that is being provided. As a result of the desire to use breast milk to minimise the risk of NEC and also maximise cognitive outcome, breast milk fortifiers (BMF) have been developed, which add calories, protein and vitamins to breast milk, while enabling the full volume of breast milk to be given (see Table 2). Cochrane14 found evidence of improved short-term weight gain, linear growth and head growth with the use of BMF and no evidence of increased risk of NEC. Nevertheless, care should be taken with addition of breast milk fortifier to minimise any risk of NEC. BLISS recommends that breast milk fortifier is used in infants <1500g at birth and <34 weeks once they are on full feeds and serum urea is <4.0mmols/l and falling15. This is because there is a correlation between serum urea and protein content of milk16. Establishing feeds
Enteral feeding will usually be established using orogastric or nastogastric tubes. Oral feeding starts to develop from 32 weeks; however, because of immature suck-swallow-breathe, most infants will not be able to breast or bottle feed totally until somewhere between 35 and 40 weeks gestation. Some units will send infants home while still tube fed, or on oxygen or both; policies differ locally depending on the services and support available to families in the community. Discharge planning
Adequate nutritional intake should be assessed as part of thorough discharge planning. For a baby
who has been on breast milk fortifier and is moving on to breastfeeding, they need to be able to take enough milk from the breast to support growth. Since breast milk fortifier is not prescribable in the community, there are limited options available if the infant does not thrive. Some units will supply breast milk fortifier for parents to mix with some expressed breast milk, alternatively families may be advised to add formula powder to breast milk or give top up feeds of post discharge or nutrient dense formula. For infants who have been on preterm formula on the unit, they will typically be discharged on a nutrient enriched post discharge formula (NEPDF), which is typically half way in composition between a preterm and standard formula (see Table 2). These also contain higher concentrations of vitamins and minerals to meet the ex-preterm infantâ&#x20AC;&#x2122;s continuing higher requirements. If an infant is breast milk fed or has a standard term formula, they will need additional vitamin and iron supplements. If an infant is unable to take sufficient volume of breast milk or a NEPDF to gain weight satisfactorily and is at or close to their due date, a term nutrient dense formula may be used (90-100kcals/100mls; 2.0-2.6g protein/100mls). These are not entirely suitable for preterm infants, but may be useful where infants are struggling to manage volumes, in conjunction with vitamin and iron supplements. Preterm infants are born at a nutritional disadvantage and the current evidence suggests that current neonatal care is not successful in helping them to overcome those early disadvantages. However, much work is going on to improve this situation in the future. Dietitians are not currently universally members of the neonatal team, despite the role of therapists including dietitians - clearly being recognised in standards and guidelines for neonatal units in England17, 18, 19, Wales20 and Scotland21. Certainly within the Wales Neonatal Network plans are underway to ensure that these standards are met in the future. The involvement of suitably trained dietitians at clinical and policy level will help to ensure that, in the future, robust, standardised evidence based enteral feeding guidelines will help to ensure that preterm infants receive the best possible nutrition from their first day of postnatal life. NHDmag.com August/September 2015 - Issue 107
29
Preterm nutrition Table 1: Nutritional requirements of preterm infants vs term infants Term infant3
Preterm infant Koletzko 20144
Preterm infant 1000g–1800g ESPGHAN 20105
95-115
110-130
110-135
Protein (g/kg/day)
2.0
3.5-4.5
Sodium (mmol/kg/day)
1.5
3.0-5.0
3.0-5.0
Potassium (mmol/kg/day)
3.4
1.9-5.0
2.0-3.5
Calcium (mmol/kg/day)
3.8
3.0-5.0
3.0-3.5
Phosphate (mmol/kg/day)
2.1
1.9-4.5
1.9-2.9
Nutrient Energy (kcal/kg/day)
4.0-4.5 (<1000g) 3.5-4.0 (1000-1800g)
Table 2: Nutritional content of milks and fortifiers Energy (kcals/100mls)
Protein (g/100mls)
Preterm breast milk
70
1.8
Preterm breast milk - >2 weeks postpartum
70
1.3
Term breast milk
69
1.3
Term breast milk + BMF
85 - 86
2.3-2.5
C&G Nutriprem 1
80
2.6
SMA Gold Prem 1
82
2.2
C&G Nutriprem 2
75
2.0
SMA Gold Prem 2
73
1.9
C&G Hydrolysed Nutriprem
80
2.6
References 1 Patole SK and de Klerk N (2005). Impact of standardised feeding regimens on incidence of neonatal necrotising enterocolitis: a systematic review and meta-analysis of observational studies. Arch Dis Child Fetal Neonatal Ed, 90, pp. F147-151 2 East of England Neonatal Network (2012). Enteral feeding on the neonatal unit. www.networks.nhs.uk/nhs-networks/southern-west-midlands-newborn-network/ guidelines-1/copy_of_guidelines/feeding-and-nutrition/Attachment%2010%20SWMNN%20enteral%20feeding%20jan%202012.pdf/view?searchterm=enteral%20 feeding%20neonatal 3 DH (1991). Dietary Reference Values: Report on Health and Social Subject No 41. London: HMSO 4 Koletzko B et al. Eds (2014): Nutritional Care of Preterm Infants: Scientific Basis and Practical Guidelines. World Rev Nutr Diet. Basel, Karger. 110, 297-299 (DOI; 10. 1159/000360195) 5 Agostoni C et al (2010). Enteral Nutrient Supply for Preterm Infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. JPGN 50: 85-9 6 Embleton NE, Pang N, Cooke RJ (2001). Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? Pediatrics (online) 107, 270-73 7 Ehrenkranz RA, Dusick AM, Vohr BR et al (2006). Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants. Pediatrics (online) 117, 1253-61 8 Franz AR, Pohlandt F, Bode H et al (2009). Intrauterine, early neonatal and post-discharge growth and neurodevelopmental outcome at 5.4 years in extremely preterm infants after intensive neonatal nutritional support. Pediatrics 123, e101-e109 9 Stephens BE, Walden RV, Gargus RA et al (2009). First week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants. Pediatrics 23, 1337-43 10 Leaf A et al (2012). Early or delayed enteral feeding for preterm growth-restricted infants: a randomised trial. Pediatrics. 2012 May;129(5): e1260-8 11 Lucas A, Gore SM, Cole TJ et al (1984). Multi-centre trial on feeding low birthweight infants: effect of diet on early growth. Arch Dis Child (online) 59, 722-30 12 Lucas A, Cole T (1991). Breast milk and necrotising enterocolitis. Lancet 336, 1519-1523 13 Schnabl KL, Van Aerde, JE, Thomas ABR, Clandinin MT (2008). Necrotising enterocolitis; a multifactorial disease with no cure. World J Gastroenterology (online) 14, 2142-2161 14 Kuschel CA, Harding JE (2004). Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane Database of Systematic Reviews, Issue 1. Art. No. CD000343. Available from http://dx.doi.org/ 10.1002/14651858.CD000343.pub 15 King C and Bell S (2010). Discussion paper on the use of breast milk fortifiers in the feeding of preterm infants. Bliss Briefings. BLISS www.bliss.org.uk/wpcontent/ uploads/2012/07/bliss_briefings_webV2.pdf 16 Polberger SK, Axelsson IE, Räihä NC (1990). Urinary and serum urea as indicators of protein metabolism in very low birthweight infants fed varying human milk protein intakes. Acta Paediatr Scan 79, 737-42 17 DH (2009). Toolkit for high quality neonatal services 18 BAPM (2010). Service Standards for Neonatal Services (3rd edition) 19 NICE (2010). QS4 - Specialist Neonatal Care Quality Standard 20 NHS Wales (2013). All Wales Neonatal Standards (2nd edition) 21 Scotland Neonatal Advisory Group (2013). Neonatal Care in Scotland: a quality framework
30
NHDmag.com August/September 2015 - Issue 107
chylothorax
Nutritional management of chylothorax patients Chyle passes from the intestinal lymphatics to the cisterna chili and then through the thoracic duct from which it will ultimately enter the venous system1. Chylothorax results in accumulation of lymphatic fluid or chyle in the pleural space following leakage from the thoracic duct. Shona Scott Cardiothoracic Dietitian, Royal Brompton & Harefield NHS Foundation Trust
For article references please visit info@ networkhealth group.co.uk
Shona Scott works as a Cardiothoracic Dietitian at the Royal Brompton & Harefield NHS Foundation Trust. In her job she treats patients with a variety of cardiac conditions and chronic lung conditions such as Chronic Obstructive Pulmonary Disease. She regularly sees patients with chylothorax following cardiac surgery.
Its aetiology can be traumatic or non-traumatic. Traumatic causes, which are most common, include cardiothoracic surgery, head and neck surgery and radiation, while non-traumatic causes can be cardiac failure, sarcoidosis, benign tumours, amyloidosis and congenital duct abnormalities2. The incidence of a chyle leak after surgery is approximately 1.0-4.0%3 and 0.2-1.0% specifically following cardiothoracic surgery4. There is scope for large amounts of fluid to rapidly accumulate in the pleural cavity as approximately 2.4L of chyle is transported through the lymphatic system every day2. Chyle is an odourless, alkaline fluid, 70% of which is absorbed dietary fat, mainly triglycerides4. In the fasting state, chyle will normally be clear but will have a milky appearance after a fatty meal. Equally, a personâ&#x20AC;&#x2122;s overall intake of fat, intestinal absorption and degree of physical activity5 will affect the fat content of chyle, but it generally ranges from 5.0-30g/litre4 or, in relation to body weight, will be between 10 Table 14: A detailed biochemical breakdown of chyle. Calories
200kcal/L
Lipids
5-30g/L
Protein
20-30g/L
Lymphocytes
400-6800/mm
Erythrocytes
50-600/mm
Sodium
104-108mmol/L
Potassium
3.8-5.0mmol/L
Chloride
85-130mmol/L
Calcium
3.4-6.0mmol/L
Phosphate
0.8-4.2mmol/L
and >100ml/kg. Chyle has 200kcal/L and a protein content of 20-30g/L6, although some studies state that this can be as high as 60g/L5. In addition, chyle contains lymphocytes, the majority of which are t-lymphocytes, fat-soluble vitamins, electrolytes and enzymes. Table 1 shows a more detailed biochemical breakdown of chyle. Presentation
Generally, chylothorax is asymptomatic until large volumes of fluid accumulate and the severity of the symptoms will be related to the rate at which the fluid accumulates and the amount of fluid in the pleural cavity1. Traumatic chylothorax normally develops within two to 10 days post injury1. The symptoms are typical of those seen with a pleural effusion and include dyspnea, coughing, chest discomfort and tachycardia7. More serious consequences of chylothorax and the most pertinent for this article are malnutrition due to the loss of protein, fats and fat-soluble vitamins4 and dehydration, hyponatraemia and hypocalcaemia due to the loss of electrolytes2. The loss of lymphocytes can lead to immunosuppression and increase the risk of infection, while the loss of large volumes of fluid can also cause hypovolaemia5. Diagnosis
Chylothorax is usually diagnosed by analysing the composition of the pleural fluid or chest drain. A triglyceride level of >110mg/dl is diagnostic of a chyle leak1, 2 and a level <50mg/dl rules out a diagnosis of chylothorax unless the patient has been fasting or is malnourished, in which case lipoprotein lipase analysis can be used4. NHDmag.com August/September 2015 - Issue 107
31
COMING SOON...
THE NEXT GENERATION MONOGEN
fa t t y a c
i ta Now con id
Monogen is a nutritionally complete*, low fat, powdered feed, for the dietary management of the following conditions:
Long chain fatty acid oxidation defects (LCFAOD) Chylothorax Lymphangiectasia Lipoprotein lipase deficiency
ni
nd T a ** CT
High M Low C L
s a n g e s s e n ti al n d L s*** CP
www.nutricia.co.uk *Suitable for use as a sole source of nutrition for infants and as a supplementary feed for children over 1 year of age and adults **100ml standard dilution (16.8g powder + 90ml water) provides: 74.6kcal; 2.2g total fat of which LCT 16% and MCT 84% ***Linoleic acid 151mg; Alpha-linolenic acid 28.6mg; and LCPUFAs: DHA 10.1mg; AA 10.1mg
chylothorax A chylothorax may exist even if the fluid is not milky and the fluid may be bloody in appearance. In nontraumatic cases, a CT abdomen and thorax should be performed to rule out malignancy2. Treatment
Consensus guidelines for the treatment of chylothorax are lacking 4, 7, but treatment can be conservative or surgical. Varying criteria are given as indications for surgery with some citing a chyle output >1000ml/day4 and others citing drain volumes that are >1.5l/24hrs or >1.0l/day over five days2, 5, or if there is persistent leakage of chyle for >two weeks2. Nutritional and metabolic complications arising from a chyle leak are also indications for surgery4. A more detailed treatment pathway can be seen below2. Conservative management includes placing the patient on a diet low in long-chain triglycerides (LCTs), whether orally or enterally, or placing the patient on a Nil by Mouth regime and using parenteral nutrition. Somatostatin is also used in some circumstances and has been used successfully in neonates4. It inhibits gastric, pancreatic and intestinal secretions, which helps to reduce chyle production1.
The key aims of nutritional management are to reduce the volume of the chyle leak (a chest drain will be in place to monitor these amounts) and to allow closure of it, to prevent malnutrition, and to replenish fluids and electrolytes that are lost4. As LCTs comprise almost 70% of chyle4, chest drain volumes can be reduced by minimising the amount of LCT in the diet. This can be done orally or enterally using a specialised enteral feed. Generally, if this is not successful in reducing the volume of chyle leak, then the patient will be commenced on total parenteral nutrition (TPN)4, 5. A review carried out by Smoke and Delegge3 did not find adequate evidence to suggest one nutritional approach was better than another, but of course it is beneficial if more invasive, risky forms of nutrition such as TPN can be avoided. Initiation of a low LCT diet and the use of MCT fat in its place resolves 50% of congenital and traumatic chylothoraces8. This variable success is attributable to the fact that any oral or enteral feeding will contribute to chyle flow and because LCTs derived from the intestine come from endogenous and exogenous sources1. Prior to starting nutritional management of a chylothorax, it is important to note the patientâ&#x20AC;&#x2122;s baseline
Figure 1: Recommended treatment pathway for chylothorax
NHDmag.com August/September 2015 - Issue 107
33
chylothorax weight and biochemistry (serum electrolytes, lymphocyte count, albumin and total protein)2 so that their nutritional status can be monitored during therapy. Those following an oral low LCT diet will have to eat larger volumes of food to meet their energy and protein requirements; consequently, those who are already nutritionally compromised and struggling to eat may be better off using enteral feeds rather than trying to follow the diet orally. Another approach is to supplement an oral diet with juice-based oral nutritional supplements, which provide valuable calories, protein and vitamins without any fat. Other fat-free or low-fat sources of protein include fat-free yoghurt and cottage cheese, fat-free or skimmed milk, egg whites and protein powders4. Some patients may require their diet to be supplemented with fat-soluble vitamins or a multivitamin and mineral supplement4. When calculating protein requirements of these patients, one should account for protein losses through the chyle leak as it contains 20-30g/L. Low LCT diet
Although there are no consensus guidelines, in practise, patients following a low LCT diet with no more than 10g of LCT daily for six weeks, will see reductions in chyle output. A previous review by McCray and Parrish9 found that dietary management is being carried out for periods ranging from one week to 24. Talwar and Lee report that two weeks is often the limit for resolution by conservative management1. A major obstacle in the success of this diet is patient confusion about what foods can be eaten and in what amounts. Therefore, patients should be given detailed diet sheets so that they are aware of hidden sources of LCT, the amounts of LCT in average portions of commonly consumed foods (fat exchange list) and foods that are free of LCT. Recipe ideas are also a useful way of improving adherence to the diet as patients can easily become bored due to the lack of palatability of lower fat foods. The Tables below show the foods that can be eaten freely on a low LCT diet, plus a typical day on a low LCT diet. It is virtually impossible to remove all fat from the diet, even vegetables such as broccoli contain 0.8g of LCT in 100g; however, patients are unlikely to be eating these foods in such large volumes that they will exceed the 10g/day threshold. It is more important that patients are made aware that they need to avoid foods that are rich in fat such as full-fat dairy products, red and processed meats, oily fish, most 34
NHDmag.com August/September 2015 - Issue 107
biscuits, cakes, puddings creamy sauces and cereals such as muesli and nut containing breads. As fat is such an important contributor of energy in the diet, these patients will need to substitute LCT with medium-chain triglycerides (MCTs). As MCTs are directly absorbed into the portal system bypassing the intestinal lymphatic system, they will provide crucial calories without contributing to chyle volumes. MCT is available as oils or in oral or enteral supplements and provides 8.3kcal/g4. MCT oil is not palatable for most patients but can work well if used in cooking or in baking. It should not be heated to a very high temperature as it has a low flash point so can burn easily. Generally, doses of 50-100mls or 385-765kcal worth of MCT oil across the day are well tolerated, but some patients will complain of abdominal pain, bloating or diarrhoea if given more4. There are several commercial MCT oils available, but they can be expensive and not all patients will be prescribed it by their GP if following the diet in the community. Enteral feeds
Specialised enteral formulas can work well to resolve a chylothorax if a patient is unable to eat sufficient amounts orally or is not adhering well to a low LCT oral diet. In addition to being MCT based, some of these formulas are also elemental. It is important to be aware that these formulas will contain varying amounts of LCT; therefore, the total intake should be calculated when planning a regimen. When deciding on an enteral nutrition regimen McCray and Parrish4 suggest that: â&#x20AC;˘ enteral nutrition may be useful if chyle output is <1000ml/day; â&#x20AC;˘ a low-fat semi-elemental formula may be effective if output is less than 500ml/day; â&#x20AC;˘ an elemental formula may be required if output is greater than 500ml/day. These recommendations are based on the literature and clinical experience4. Parenteral nutrition
In unresponsive cases of chylothorax, or when nutrients are being lost rapidly into the pleural space, TPN is indicated5. Reports find that patients with a drain output of >1000ml while NBM will likely require TPN4. As lipids containing TPN do not enter the lymphatic system they will not contribute to chyle production and can be used safely.
chylothorax Table 2: Foods which can be eaten freely All fruits including fresh, tinned, or frozen (excluding olives and avocado) All vegetables including those pickled in vinegar Sugar, honey, golden syrup, treacle, jam Jelly, boiled sweets, mints (not butter mints) Fruit sorbets, water ices, ice lollies, very low-fat frozen yoghurts Meringue, egg white, egg replacer Spices and essences, salt, pepper, vinegar, herbs, tomato ketchup, chutneys, Marmite, OXO, Bovril Fruit juices, fruit squash, fizzy drinks and milkshakes made with skimmed milk and Crusha syrup or Nesquik Table 3: Example of dayâ&#x20AC;&#x2122;s menu on 10g LCT diet Breakfast: 1 glass of fortified (CHO powder) orange juice Toast x 2 with 100g of baked beans and omelette (1 egg white cooked with MCT oil) Lunch: 200mls fat-free soup Cooked pasta (90g raw) with 150g tinned tuna in brine, vegetable and tomato sauce (cooked with MCT oil as required) High-energy jelly (fortified with CHO powder) 1 fat-free yoghurt Dinner: Fish cakes (60g of white fish, 60g boiled potatoes, 20mls skimmed milk to bind, use egg white and 1 slice of white bread for breadcrumbs) fried in MCT oil Mashed potatoes (with skimmed milk) and boiled vegetables Strawberry milkshake with 200mls of skimmed milk with flavoured powder Fruit salad Offer 3 x 200ml bottles of juice-based oral nutritional supplements throughout the day Essential fatty acids
Patients who follow an oral low LCT diet for more than three or four weeks will require supplementation with essential fatty acids (EFA)4. Linoleic acid is the required fatty acid as the body is unable to produce it. Linolenic acid and arachidonic acid can be made from the body if it has a sufficient source of linoleic acids. Daily requirements of EFA will be met by providing 2.0 to 4.0% of calories as linoleic acid4. This can be done using a range of easily available oils (walnut, wheat germ, sunflower), which can be used as salad dressings or added to foods such as pasta after cooking. If using walnut oil, 1.4tsps would provide four percent of energy for every 1000kcal4. Most enteral formulas will meet EFA requirements if used in specific volumes, as will lipid-containing parenteral nutrition formulations. The sedative propofol will also provide a source of EFA, a 150ml infusion would meet the EFA needs of a person who requires 2000kcal per day4.
Summary
Despite the fact that dietary manipulation is such an integral part of the conservative management of chylothoraces, there is a distinct lack of evidence-based guidelines. The literature on the use of enteral or parenteral nutrition for its management is largely based on small observational trials, small retrospective trials and case reports7. It is important to do a full nutritional assessment of the patient prior to choosing the appropriate regimen, be it oral, enteral or parenteral or a mix of these. Barriers to adherence to an oral low-fat diet should be alleviated by giving detailed oral and written guidance to patients about those foods that can be eaten freely, the fat content of foods and recipe ideas. Each patientâ&#x20AC;&#x2122;s need for additional supplementation with EFA and a multivitamin and mineral supplement should be considered. A patientâ&#x20AC;&#x2122;s nutritional plan should be regularly monitored to ensure that it is effective in reducing chyle output and that nutritional status is not being compromised. NHDmag.com August/September 2015 - Issue 107
35
Web watch
web watch Online resources and useful updates.
Poor care for older hospital patients Researchers from the London School of Economics (LSE) have published Older people’s experiences of dignity and nutrition during hospital stays: Secondary data analysis using the Adult Inpatient Survey. This report finds that older hospital patients in England face a ‘widespread and systematic’ pattern of inadequate care. An estimated one million people in later life are affected by poor or inconsistent standards of dignity or help with eating in hospitals. The report comes from data in the Adult Inpatient Survey for 2012-13 to provide a detailed picture of older people’s reported experiences during hospital stays. http://sticerd.lse.ac.uk/ dps/case/cr/casereport91.pdf GP Prescribing in 2014 The House of Commons library has published its latest briefing paper GP Prescribing in 2014: constituency statistics. Prescription rates for medicines and treatments provide one useful measure of the burden of illness and disease across the country. This paper provides statistics on prescriptions by GP practices in England as a whole and local variation for individual drugs and treatments. In 2014, an average of 18.4 items were prescribed in primary care for each patient registered with a GP practice in England. This amounts to a total of just over one billion items prescribed. The total list price
36
of these items was £8.6 billion around £152 per head, with an average cost per item of £8.20. http://researchbriefings.parli a-ment.uk/ResearchBriefing /Su m mary/CBP-7161
Pharmacists plan to ease GP workload Up to 250 clinical pharmacists are to be recruited to GP practices to provide direct patient care and help to ease workload. The £15m, three-year pilot project for England will see pharmacists support about one million patients with self-limiting illnesses or long-term conditions. It is part of the GP workforce 10-point plan agreed between the BMA GPs committee, Royal College of GPs, NHS England and Health Education England. http://bma. org.uk/news-views-analysis/ news/2015/july/pharmacistsplan-to-ease-gp-workload Mental health key facts app The Royal College of Psychiatrists has launched a new app giving access to the College’s mental health information leaflets, videos and podcasts. RCPsych Key Facts App is available from iTunes and Android Play Store. www.rcpsych.ac.uk/ healthadvice/atozindex.aspx Allergy sufferers put at risk from fast food takeaways An undercover investigation
NHDmag.com August/September 2015 - Issue 107
by the Royal Society for Public Health has found that just over two thirds of takeaways are not declaring the presence of any of the 14 major allergens used as ingredients in their food. The investigation, which included 10 types of takeaways, found chicken shops to be the worst offenders. Legislation introduced in 2014 requires takeaways to be able to declare the presence of any of the 14 major allergens, provide notices in a clear visible format and have a system in place to ensure information can be checked, is accurate and consistent. www.rsph.org.uk/ en/policy-and-projects/areasof-work/allergies.cfm
Oesophago-gastric cancer awareness campaign: interim results The National Cancer Intelligence Network has published Be Clear on Cancer: oesophagogastric cancer awareness regional pilot campaign: interim evaluation report. A regional oesophagogastric cancer awareness campaign ran in the North East of England from 10 February to 9 March 2014. This interim report provides available results to date from an evaluation of the effectiveness of the campaign. A full and final evaluation report will be published when the analysis of all metrics is complete. Available at www.web. nhs.net with user login.
web watch Promoting healthy diets among children and young people The BMA has published Food for Thought: promoting healthy diets among children and young people. This report sets out the measures needed to help promote healthier diets among children and young people. It recommends a range of interventions focused on improving attitudes and knowledge; limiting unhealthy cues and irresponsible retailing practices and creating a healthy food environment. Some of the measures aim to directly protect children and young people, while others are to help parents and carers in making the right choices. http://bma.org.uk/ working-for-change/improvingand-protecting-health/food-forthought Improving health and wellbeing through digital technologies The top prize in the People Driven Digital unAwards has been won by an online app which can help save the life of a person experiencing cardiac arrest. The Lifesaver app acts as an interactive crisis simulator which uses live-action film to teach the user how to perform CPR and use an automated defibrillator. Further details of all the finalists and the winners for each award category, which includes My COPD, Brush DJ, Timesulin and iPad engage, can be found here: http://mhealthhabitat.co.uk/pddaward-finalists/ Dementia care The Alzheimerâ&#x20AC;&#x2122;s Society has published its fourth annual report Dementia 2015: aiming higher to transform lives. This report looks at the quality of life for people with
dementia in England and contains the results of the Societyâ&#x20AC;&#x2122;s annual survey of people with dementia and their carers, plus an assessment of what is currently in place and needs to be done to improve dementia care and support in England over the next five years. It makes practical recommendations to the new government on the steps that need to be taken to make quality of life better for people with dementia. www.alzheimers. org.uk/site/scripts/documents_ info.php?documentID=2888 Physical activity in children Public Health England has published Change4Life Evidence Review: rapid evidence review on the effect of physical activity participation among children aged 5-11 years. This rapid evidence review aims to identify relevant literature on the physiological, psychological, social and behavioural outcomes of physical activity participation among children in that age group, and provide an indication of the strength of the evidence for each outcome. www.gov.uk/government/publications/change4lifeevidence-review-on-physical-activity-in-children Management of iron deficiency anaemia The Royal College of Nursing has published new guidance on iron deficiency and anaemia in adults. This guidance has been published along with other new resources on the topic and is aimed at all nurses, healthcare assistants, midwives and health visitors from all specialties and backgrounds. www.rcn. org.uk/newsevents/news/article/ uk/new-guidance-for-the-management-of-iron-deficiency-anaemia
Record seizure of counterfeit and unlicensed medicines and devices made in UK The Medicines and Healthcare products Regulatory Agency has announced ÂŁ15.8 million worth of counterfeit and unlicensed medicines and devices that have been seized in the UK as part of a global operation. The seizures, the biggest recorded to date in the UK, include large quantities of illegally supplied and potentially harmful slimming pills, anaemia tablets and narcolepsy tablets. Unlicensed foreign medicines were also found and removed. www.gov.uk/government/news/ uk-leads-the-way-with-158-million-seizure-in-global-operationtargeting-counterfeit-and-unlicensed-medicines-and-devices Rare and less common cancers The National Cancer Intelligence Network in collaboration with Cancer 52 has published Rare and less common cancers: Incidence and Mortality in England, 2010 to 2013. Rare and less common cancers make up just under half of all newly diagnosed cancers: 47% for 2013 in England for both males and females. As of 2013, there are around 2700 more deaths annually from rare and less common cancers than in 2010. Counts and crude rates are presented for 278 rare and less common cancer sites for incidence figures and 95 sites for mortality figures. The data covers the period 2010 to 2013 and is broken down by year and sex for England. Data relating to many of these sites has not been published routinely before. www. ncin.org.uk/publications/
NHDmag.com August/September 2015 - Issue 107
37
dysphagia
Dysphagia product update This is now the second update of this article (first published in NHD in 2011). Since the last update in 2013, a few new products have become available, but what feels most significant to me is the first advertisement I have ever seen in a national, mainstream magazine for pureed food, suggesting that recognition of the need for modified texture food is growing. Alison Smith RD Prescribing Support Dietitian, Chiltern CCG and Aylesbury Vale CCG
For article references please visit info@ networkhealth group.co.uk
Many older people who suffer from dementia or a number of other conditions, or who have had a stroke continue to live with dysphagia, and an Australian review study found that dysphagia in older adults occurs in: • 13% of free living population • 25% of those in hospital • 60% of those resident in nursing homes1 Understanding the food and fluid textures required for people with dysphagia is, therefore, important for any dietitian working with older people. It is also important to have some knowledge and understanding of the products currently available, to help achieve both advised texture and an adequate nutritional intake. However, evidence of the benefits of texture modification of both fluid and food and the most advantageous textures is surprisingly scant2. THICKENERS
Alison specialises in appropriate prescribing of nutritional products and in appropriate identification and treatment of malnutrition, especially in older people living in the community and in care homes. Alison is a committee member of the BDA Older People Specialist Group.
38
Prescribed thickeners are used to thicken fluids to a more viscose consistency than normal, because drinking thicker fluids has long been thought to reduce risk of aspiration for people with dysphagia. A recent systematic review has identified that thickening liquids can reduce risk of aspiration, but thickened fluids can also increase risk of residue remaining in the pharynx after swallowing (Steele et al 2015) which could then be aspirated at a later stage. Other studies have suggested use of a ‘free water protocol’ for people with dysphagia who meet
NHDmag.com August/September 2015 - Issue 107
certain criteria, but this is only likely to be appropriate for those who are both mobile and have ‘relatively healthy cognitive function’3, 4 which may rule out the majority of older people with dysphagia. Having said all of this, at least for the time being, thickened fluids remain a cornerstone of dysphagia management in the UK. Thickeners can also be used to provide consistency in pureed food, preventing purees from splitting into solid and liquid once pureed. Starch based thickeners (see Table 1) The majority of thickeners are still made from modified starch which, when mixed with fluid, can have several less than desirable characteristics. Mouth feel can be ‘granular’ rather than smooth, which can be off-putting for patients, and most starch based thickeners also have the disadvantage of being sensitive to amylase (a component of saliva). This can be a significant issue because saliva will be introduced to the thickened drink from the first sip. If, as is common in dysphagic patients, it takes a long time to finish a drink, the action of amylase on the thickener can result in the drink in the glass or cup separating into two or more textures over a period of time, or can result in the action of the thickener being lost altogether5 - both of which may increase risk of aspiration. However, the action of amylase on starch-based thickeners is also dependent on pH of drinks and Hanson et al6 found that, while amylase broke down
dysphagia thickener in water very quickly, it did not have the same action when thickener was mixed with orange juice. Starch-based thickeners can take a few minutes to thicken to the correct texture and it is not uncommon when a drink does not thicken instantly, for patients or carers to add extra thickener, thinking that the amount they added initially was insufficient. This can obviously result in the drink becoming significantly thicker than the advised consistency, which can impact on the safety of swallowing2 and is likely to reduce palatability, as the thicker a drink is, the less well it tends to be tolerated5, 7. The way that starch-based thickeners work also means that a drink thickened with a starchbased thickener tends to continue to thicken over time, so that even if the correct texture is achieved initially, the drink may become thicker the longer it is left8. Again, as people with dysphagia can take a long time to consume a drink, this is of real concern if intake of thicker drinks can increase risk of residue remaining in the pharynx2. Gum based thickeners (see Table 2) In the last few years, several thickeners containing gums, either instead of or in addition to starch, have been launched. There can be some significant advantages to these products in terms of safety and palatability - gums are not broken down by amylase, making them potentially safer products and gum-based thickeners may not cause the same â&#x20AC;&#x2DC;granularâ&#x20AC;&#x2122; texture in thickened drinks as starch-based thickeners. The thickening process of gums is also different to that of starch, so that they tend to thicken more quickly and maintain their texture for longer, so that drinks containing gum-based thickeners should not get thicker over time. However, introduction of saliva (and therefore amylase) to a drink thickened with a combination of starch and gums, may still result in the fluid breaking down into a thinner consistency5. It is also important to note that not all gumbased thickeners will thicken drinks immediately, and because gum-based thickeners behave differently to starch-based thickeners, a different technique may need to be used when adding them to drinks. This is particularly pertinent
when considering thickeners prescribed for use in care homes, as without training, staff may be unaware that gum-based thickeners require a different mixing technique. Concerns have been raised regarding the bioavailability of water when gum-based thickeners are used because, unlike starches, gums tend not to be broken down until they reach the large intestine. A review by Cichero found only two studies which had investigated this concern and both found no impact of thickening on bioavailability of water, regardless of the type of thickener used1. Usually, fluid needs to be added to a gumbased thickener and, once mixed, no further thickener can be added. Most scoop sizes for gum-based thickeners will thicken 100ml fluid to stage 1, which is appropriate for drink volumes. However, liquid medications are also likely to need to be thickened and, although the volume per dose tends to be significantly smaller than 100ml, a smaller measure is not currently provided to accommodate this requirement. This means that liquid medications may be given in their unthickened state or, alternatively, thickened to a different texture than that advised. OTHER CONSIDERATIONS
Mertz Garcia et al8 and Sopade et al9 found that many different factors (including pH, fat and protein content) can influence how thickeners interact with different fluids. This means that different types of fluid may need different amounts of thickener added in order to achieve the same texture. Thickening fluid can slow its transit through the mouth which, as well as potentially helping to achieve a safe swallow, can also affect how taste is perceived. This means that the person who requires thickened fluid may find that drinks they would normally enjoy now taste less pleasant, which of course can put people off drinking adequate fluid or using thickener as advised. Several studies have demonstrated that people with dysphagia frequently fail to consume adequate fluid, and that increased fluid viscosity correlates with lower fluid intake7, 10. It is also interesting to note that when stage 3 fluids are taken as small spoonfuls (as may be advised by speech and language therapists), this, together NHDmag.com August/September 2015 - Issue 107
39
Nutilis Clear has been designed to maintain the original appearance of drinks, which may support compliance and improved fluid intake.
The new MyNutilis.co.uk website aims to inspire patients and carers to cook delicious meals with Nutilis Clear. Visit the website for recipes, news items and videos of Chef Neil making meals that look and taste appealing to patients.
Tin Size (g)
FP10 Price*
Cost per Stage 1 drink**
No. of Stage 1 drinks** per tin
Nutilis Clear
175
£8.46
£0.15
58
Nutilis Powder
300
£4.92
£0.13
37
Thick & EasyTM
225
£5.06
£0.20
25
Resource ThickenUp® Clear
125
£8.46
£0.16
52
*MIMS, March 2015; **200ml drinks as per manufacturer dosage instructions.
Transparent results MyNutilis.co.uk
dysphagia Table 1: Starch based thickeners
Product
Multi-Thick Nutilis Powder Resource ThickenUp Thick and Easy Thicken Aid
Thixo-D Original Vitaquick
Thickener ingredients
Cost per tub (£)
Quantity of thickener required per month to thicken 1600ml fluid per day to stage 1 (kg)
Abbott
Modified maize starch
4.83/250g
1.814
35.05
Nutricia
Modified maize starch
4.92/300g
1.792 – 2.688
29.39 - 44.08
Nestlé
Modified maize starch
4.55/227g
2.016
40.41
Fresenius Kabi
Modified maize starch
5.06/225g
2.016
45.34
M&A Pharmachem
Modified maize starch Maltodextrin
3.71/225g
2.016
33.24
Sutherland
Modified maize starch
5.79/375g
2.24
34.59
Vitaflo
Modified maize starch
7.05/300g
1.500
35.25
Manufacturer
with the increased oral transit time, means that even those without dysphagia tend to consume 1.2 to 1.3 times less fluid than if the fluid was taken as larger mouthfuls and if the fluid had a shorter oral transit time1. Dehydration can, therefore, be a significant risk for those requiring thickened fluids. Reducing risk of aspiration may reduce the likelihood of chest infections and aspiration pneumonia and, therefore, reduce or avoid the costs of treating these conditions (prescription of antibiotics with or without acute admission). However, it is also important to remember the other potential costs of failing to thicken fluids adequately or palatably. If thickened fluids are unpalatable, patients may choose to drink unthickened fluids or to drink an inadequate volume of thickened fluids, thereby increasing their risk of aspiration and/or dehydration, UTIs and constipation, all of which can result in healthcare costs, as well as reduced quality of life for the patient. Storage of thickeners on wards and within care homes may also needs careful consideration following publication of an NHS Patient Safety Alert11 earlier this year regarding the need to safeguard patients who could be at risk of ingesting thickener powder, following the unfortunate death of one patient who did this.
Prescription cost per month of thickening 1600ml fluid per day to stage 1 (prepared according to manufacturer’s instructions (13) (Costs from MIMS June 2015) (£)
Considerations when requesting or reviewing prescriptions Cost pressures within the NHS continue to be significant and as health professionals we all need to be mindful of the costs of the products which we may discuss with patients or request GPs to prescribe. As in the previous versions of this article, I have included current prescription costs of all the products listed below to aid consideration of cost effectiveness. It is important though to note that, in many acute settings and in some community settings too, contracts with nutrition companies may render specific products significantly cheaper than the FP10 (prescription) prices quoted. GPs are likely to need guidance so that they understand the quantity of thickener required to thicken an adequate amount of fluid each day to the recommended consistency. I regularly come across prescription of only one or two tubs of thickener per month due to GPs’ lack of knowledge of these products. To thicken the minimum daily fluid requirement of 1600ml12 to stage 1 each day for one month will require four to five tubs of a gum-based thickener and six to nine tubs of a starch-based thickener. In my experience, GPs can be surprised when asked to prescribe an adequate amount of thickNHDmag.com August/September 2015 - Issue 107
41
dysphagia Table 2: Gum based thickeners
Product
Thickener ingredients
Manufacturer
Nutilis Clear
Dried glucose syrup tara gum
Nutricia
Resource ThickenUp Clear Thick and Easy Clear Thixo-D CalFree
Cost per tub (£)
Quantity of thickener required per month to thicken 1600ml fluid per day to stage 1 (kg)
according to manufacturer’s instructions (13) (Costs from MIMS June 2015) (£)
8.46/175g
0.672
32.49
Prescription cost per month of thickening 1600ml fluid per day to stage 1 (prepared
nestlé
xanthan gum maltodextrin
8.46/125g
0.537
36.34
Fresenius Kabi
maltodextrin xanthan gum Carageenan
8.80/126g
0.627
43.79
sutherland
xanthan gum
2.57/30g
0.280
23.99
Prescription cost per serving (and cost per month if 1600ml fluid provided per day) (MIMS June 2015) (£)
Table 3: Pre-thickened drinks
Product
Resource Thickened Drinks Slõ Drinks
Manufacturer
Consistency available
Volume
Nutritional content per serving
Nestlé
‘Syrup’ ‘Custard’
114ml cup
101-103 kcal (both textures)
0.71 (279.02)
Slõ Drinks
Stage 1 (cold/hot) Stage 2 (cold/hot) Stage 3 (cold)
115ml cup (requires addition of water)
24-57 kcal 30-63 kcal 56-57 kcal
0.30 (116.87)
ener, but may then realise that their previous inadequate prescribing could have been putting patients at risk. GPs are also likely to need clear advice regarding exactly which product is required (and which is not), as the similarity of many of the thickener names (when both starch- and gum-based thickeners are produced by the same company) may otherwise result in the wrong product being prescribed – again, I come across this error in prescribing very frequently and care home staff and patients may not notice that the product which is prescribed is not correct. Slõ Drinks, best known for producing prethickened drinks, have recently developed thick42
NHDmag.com August/September 2015 - Issue 107
eners specific to types of fluid which tend to be more difficult to thicken safely and palatably namely alcohol and fizzy drinks. These products are not currently ACBS listed, therefore cannot be prescribed, but are available to purchase. PRE-THICKENED DRINKS
Pre-thickened drinks can be helpful for patients who find it difficult to prepare thickened drinks, for example due to limited manual dexterity or poor eyesight, and there are two products currently on the market, one of which requires the addition of water. The cost of pre-thickened drinks can be an issue, but in some cases, these products may
dysphagia Table 4: Thickened ONS - Stages 1 and 2 Manufacturer
Consistency available
Volume
Nutritional content per serving
Prescription cost per serving (MIMS June 2015) (£)
Fresubin Thickened
Fresenius Kabi
Stage 1 Stage 2
200ml
300kcal 20g protein
2.28
Nutilis Complete
Nutricia
Stage 1 Stage 2
125ml
306kcal 12g protein
2.21
Product
Table 5: ONS - Stage 3 Manufacturer
Volume
Nutritional content per serving
Prescription cost per serving (MIMS June 2015) (£)
Ensure Plus Crème
Abbott
125g
171kcal 7.1g protein
1.88
Forticreme Complete
Nutricia
125g
200kcal 11.9g protein
1.96
Nutilis Fruit Stage 3
Nutricia
150g
200kcal 10.5g protein
2.36
Fresubin 2kcal Creme
Fresenius Kabi
125g
250kcal 12.5g protein
1.93
Fresubin Yocreme
Fresenius Kabi
125g
187kcal 9.3g protein
1.98
Nutricrem
Nualtra
125g
225kcal 12.5g protein
1.40
Resource Dessert Energy
Nestlé
125g
200kcal 6g protein
1.59
Product
still be a cost-effective choice. Pre-thickened drinks tend not to have the ‘granular’ texture of an added starch-based thickener, which may aid compliance and thereby increase fluid intake. They should also automatically be the correct texture for the patient, which may help reduce risk of aspiration. Therefore, use of prethickened drinks may help to reduce common health risks (dehydration and aspiration) for the patient with dysphagia. Having said that, the texture descriptors are different for each product which can be confusing and make choosing the correct consistency more difficult. PRE-THICKENED ORAL NUTRITIONAL SUPPLEMENTS (ONS)
How to achieve a consistently thickened ONS has been an issue within all care settings for years, so pre-thickened sip feeds have certainly filled a gap in the market.
There are two companies currently producing pre-thickened ONS in Stage 1 and Stage 2 consistencies, and dessert type ONS made by all nutrition companies are usually suitable for patients requiring Stage 3 thickened fluids. Pre-thickened ONS do cost more than nonthickened equivalent products, but the cost of the thickener and cost of the consequences of inappropriately thickened (or unthickened) sip feeds must also be taken into account when looking at the overall cost incurred. For example, Fresubin Thickened costs £2.28 per bottle compared with Fresubin Protein Energy which costs £2.02 per bottle; however, sufficient Thick and Easy or Thick and Easy Clear to thicken the latter to Stage 1 would cost approx 20p. In addition, pre-thickened ONS are guaranteed to be the correct texture without any preparation time or issues around consistency which may help reduce risks of both aspiration and malnutrition for the patient with dysphagia. NHDmag.com August/September 2015 - Issue 107
43
dysphagia PUREED FOOD
Several companies, including Apetito/Wiltshire Farm Foods, Oakhouse Foods, Kealth and Simply Puree produce pureed meals for adults with dysphagia and most offer home delivery for individuals and some are also offered by Meals on Wheels services. Thickener is added to most of these pureed foods to maintain texture and if the thickener used is starch based, the same concerns regarding maintaining consistency once the food comes into contact with saliva and, therefore, amylase exist as for drinks. Again if a patient takes a long time to swallow the food or transfers saliva from their mouth to the plated food, this can result in the food splitting into solid and liquid, potentially increasing risk of aspiration. Many of the dishes available are moulded so that their appearance is better than can easily be achieved for food pureed in either a
domestic environment or many care environments. Some of these companies also ensure that the energy and protein content of the meals is high. This is especially important as the nutritional intake of those consuming pureed food tends to be lower than that of equivalent patients consuming normal food, and patients having pureed food frequently fail to meet their nutritional requirements for either energy or protein14. CONCLUSION
Prevalence of dysphagia is high in the ageing population and as the ageing population grows, is likely to become more of an issue in the coming years. Having an understanding of the dysphagia products available will help when advising patients with dysphagia and when working with colleagues, especially speech and language therapists and GPs.
NHDmag.com . . .
. . . Your essential resource 44
NHDmag.com August/September 2015 - Issue 107
A DAY IN THE LIFE OF . . .
. . . a dietitian Down Under
Claire Riley, Dietitan (Accredited Practising Dietitian in Australia, APD), Lady Cilento Children’s Hospital
I have been working as a dietitian in Australia for the past three years. I passed the DAA (Dietetics Association of Australia) exams, which were some of the most stressful and expensive exams I have ever taken in my life! After this, I was lucky enough to get a job in a large teaching hospital in Brisbane, Queensland. My preferred area is paediatrics, so I worked in every area there was whilst waiting for a paediatric job to come up! LEARNING THE DIFFERENCES
Claire has experience working in Ireland, the UK and Australia. She completed research in the United States on obesity and in sports nutrition in the UK. Claire is passionate about working in paediatric dietetics. Her dietetic experience spans across adults, paediatrics, community and sports nutrition.
I currently work in a tertiary children’s hospital in Brisbane, Lady Cilento Children’s Hospital. Many aspects of my day-to-day job are similar to my time working as a dietitian in Ireland and the UK. However, some things here are vastly different. KJs
Whist studying for the DAA exams, I realised that Australia uses Kilojoules/ Megajoules instead of calories, which is a difficult concept to grasp as a dietitian trying to do calculations and working in numbers that can go into tens of thousands! Thankfully, now where I work, we talk in calories and I don’t need to divide everything by 4.2 for it to make sense.
Foods & Drinks
I spent many happy hours wandering around the supermarkets trying to memorise name of foods and brands (so I can ask my favourite question, “Is it the blue top milk you have?”). After learning the proper names of everything, I then had to go back and try to understand all the slang words and abbreviations that people use over here. My first diet history consisted of something like this (see Table 1). As well as understanding the complexities of Aboriginal foods and culture, I also had to learn the dietetic lingo; saying ‘serve sizes’ instead of portions and asking about tablespoons and cups instead of grams. When being sick is ‘crook’
Learning the medical abbreviations felt like I had to learn another language (note: nasojejunal feeds NJ = TPT - trans pyloric tube?!). I am thankfully familiar with many of the feeds that we use (i.e. Nestle, Nutricia, Abbott) although the range is much smaller. I find myself lamenting over flavours that we don’t
NHDmag.com August/September 2015 - Issue 107
45
A DAY IN THE LIFE OF . . . Table 1 The meal
What was said
What it means
Breakfast
Rice Bubbles and a Milo
Rice crispies breakfast cereal and a flavoured milk drink
Lunch
Cheerios, toast with nuttlex, an LCM bar and a popper
Small sausages, toast with a brand of butter, a breakfast type bar and a juice drink
Dinner
Hot chips, zucchini with rissoles
Chips, courgettes, small balls of fried mince
Snacks
Pikelets/lamingtons/ice block/lollies/
Small pancakes/a type of cake slice/iced lolly/sweets
have here, but I did quickly learn that it’s not helpful to tell patients, “Well, if you were in the UK, you could get that flavour!” Formulas and feeds
Formulas and feeds here are discussed in kcal/ml, kcal/30ml, percentages, kJ/ml and in strengths, i.e. ‘1.25%’ strength. This was mind boggling for checking and rechecking my calculations and also for educating families. There can be updates sent to us by the feed companies that certain feeds are out of stock or, are in short supplies reaching Australia. I quietly pray that none of my families hear about these shortages and everything comes on time. If not, panic can spread and I get dozens of calls from families demanding to know what’s happening with their deliveries. Costs
Cost is significantly different to the UK and Ireland. Patients in Queensland need to pay a subsidised amount for their feeds, consumables and deliveries. As a result, I am more considered in my approach to recommending nutritional supplements and feeds to families. Using the golden oldie ‘High Protein High Calorie’ information can be the best advice I give out when financial considerations are involved. This has forced me to think outside of the box and let go of my rigidity with prescribing nutritional supplements! AUSTRALIA’S PUBLIC HEALTH MESSAGE
Australia also has a totally different public health nutrition message, which I was initially shocked to discover. Australia follows 46
NHDmag.com August/September 2015 - Issue 107
the ‘5 & 2’ recommendation for fruit and vegetables (5 = vegetables, 2 = fruit). There is no UK healthy plate model or food pyramid. All of a sudden, the ‘five-a-day’ motto for fruit and vegetables that I once treasured wasn’t enough. I sometimes think I should be over compensating for all the vegetables I missed out on to make up for this huge deficit. I take my dietetic clinics very seriously here, knowing that some families have driven for hours, or have flown their entire family down for my appointment and left their farms and properties. I am very aware of the difficulties that some families have living remotely, including their access to food, local healthcare and sometimes even telephone coverage. In these instances, I need to make up feeding plans that cover a wide range of issues. This has been a really challenging learning experience for me as a dietitian, forcing me to think ahead and plan for every eventuality without overwhelming the families. I have found Australian medical teams much more informal than those in Ireland or in the UK. I often see my consultants at work in jeans/shorts and insist on everyone including families use their first names (and nicknames!) at ward rounds and appointments. Consequently, I’m far more able to ask my silly questions and put forward my suggestions to teams in this relaxed work environment. Overall, moving to Australia and working as a dietitian has been an incredible experience and I would encourage anyone who wants to move here to come. But start studying for the exams now!
career
To place a job ad here and on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) dieteticJOBS.co.uk
DIETITIAN SENIOR II - GIBRALTAR HEALTH AUTHORITY: £28,371 to £37,383 pa Now is your opportunity to sample the Mediterranean way of life. Gibraltar, a British dependency on the southernmost tip of the Iberian Peninsula is the ideal base for exploring the delights of Southern Spain and the magical North African continent. We are looking for an enthusiastic, experienced and highly motivated Band 6 Dietitian, with a broad-based background in general dietetics. The successful candidate will have a varied caseload including acute (medical /surgical) wards, long stay wards and general outpatient clinics, as well as providing training/education for nursing staff as required. You would be part of a team of three highly experienced Dietitians who would provide you with clinical supervision and support. The appointment will be on contract terms for a period of 10 months to cover a period of maternity leave. Please contact Ms Katrina Skilton, Senior Dietitian, tel: 00350 20072266 ext 2199 or email: katrina.skilton@gha.gi. Application Packs are obtainable from the Recruitment Section on ext 2081 or Fax: 00350 20043864 or e-mail: kevin.galliford@gha.gi. Closing Date: Monday 17th August 2015
Paediatric Dietitian - Norfolk A Paediatric Dietitian is required from 10th August for four weeks covering general paediatric outpatient clinics and general ward work, seeing children with faltering growth, allergies and fussy eating. For this or other
dietetic vacancies with Elite, please contact Hayley on 0800 023 2275, or email your CV and interest to hayley@eliterec.com www.elitedietitians.com
Continued . . .
We urgently require dietitians for immediate vacancies To find out your options call or email Freephone: 0800 032 0454 Registration@pjlocums.co.uk
• PJ Locums is an NHS Buying Solutions framework approved supplier for allied health • Our aim is to find you the right person and the right job • We offer inpatient and community UK & NI coverage • Competitive rates
www.pjlocums.co.uk NHDmag.com August/September 2015 - Issue 107
47
career Band 6 Acute Dietitian Basildon, Essex Band 6 Dietitian required for four days for seven weeks. Stroke and surgery experience required. 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 Paediatric Dietitian Essex Colchester This job entails general paediatric dietetics, including the children’s ward and paeds clinics. Clinics may include general paeds, oncology clinics, CF MDT clinics and home feeds. This role is covering a fixed-term contract, so they are looking for a locum to fill the role for at least three to four months while they recruit. There would, therefore, be an option for the role to switch to the fixed-term contract. To be considered, please email Hayley@eliterec.com or call 01277 849 649, or visit www.elitedietitians.com Paediatric Dietitian three days a week (Essex) Starting 12/8/15. This would be someone with paeds experience at Band 6/7. Two days a week in North East
London and one day a week at Romford. Caseload is a mixture of clinics/children’s centre drop-ins/weight management programme. For this or other dietetic vacancies with Elite, please contact Hayley on 0800 023 2275 or email your CV and interest to hayley@eliterec.com, or visit www.elitedietitians.com Band 5/6 Community Dietitian 2.5 days a week (Berkshire) Starting ASAP to cover an Adult and Paediatric caseload, involving clinic. Likely length of contract will be until March 2016. 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 Paediatric Community Dietitian – Berkshire - ASAP Two days a week of Specialist Community Paediatric cover, to work within CYPIT services (children and young people’s integrated therapies) until next summer 2016. For this and other dietetic vacancies with Elite, please contact Hayley on 0800 023 2275 or email your CV and interest to hayley@eliterec.com, or visitwww.elitedietitians.com
The Number 1 agency for Dietetic Recruitment Elite Recruitment are a specialist supplier to private hospitals & commercial companies. We are a preferred supplier to NHS trusts nationwide and are the only agency dedicated to dietetic recruitment.
JOB OF THE MONTH
ADULT AND PAEDIATRIC DIETITIANS REQUIRED We are urgently looking for experienced dietitians to cover positions across the whole of the UK. We have Full and Part Time Posts available in both Acute and Community settings Excellent rates of pay – up to £35.00ph.
Can you afford to miss out on registering with elite? The only recruitment agency to supply solely to the Dietitians industry for commercial and private companies across the UK. Either call or email your interest today and receive our free job alerts.
0800 023 2275 info@eliterec.com www.elitedietitians.com 48
NHDmag.com August/September 2015 - Issue 107
CAREER Specialist Paediatric Dietitian - S England Band 7 Specialist Paediatric Dietitian with experience of diabetes, carbohydrate counting and insulin pumps for an ongoing post. The role is hospital based in the South of England. Email your CV to registration@pjlocums. co.uk. Our rates are competitive in the current market; we offer assistance with relocation and hospital accommodation. We provide you with a current CRB, full occupational health check and can organise your mandatory training. PJ Locums is an NHS Government Procurement and LPP framework approved supplier for Allied Health, Health Science personnel and nurses. Band 7 Dietitian - Immediate Start A busy Central London hospital is looking for a Band 7 Dietitian immediate start. Must have experience in diabetes: pumps, dose adjustment, complication clinics. Email your CV to registration@pjlocums.co.uk. Our rates are competitive in the current market; we offer assistance with relocation and hospital accommodation. We provide you with a current CRB, full occupational health check and can organise your mandatory training. PJ Locums is an NHS Government Procurement and LPP framework approved supplier for Allied Health, Health Science personnel and nurses.
dieteticJOBS.co.uk The UK’s largest dietetic jobsite
To place a job ad in NHD magazine or on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate)
events and courses University of Nottingham - School of Biosciences
Modules for Dietitians and other Healthcare Professionals
• Public Health Nutrition Policy - 19th Nov, 2015 • Diabetes 1 & 2 - 14th Jan, 2016 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’ 14-16th Aug - International Critical Dietetics Conference Manchester International Conference Centre www.criticaldietetics.org 4th-6th Sep - BSACI Annual meeting The British Society for Allergy and Clinical Immunology Telford International Conference Centre, Telford www.bsaci.org/meetings-and-events/index.htm 9th Sep - BDA Branch CPD Meeting NW England North Wales Branch Lance Dobson Hall, University of Chester Warrington Email: belinda.mortell@wales.nhs.uk 11th Sep - Recipe Analysis: Maximising Accuracy Nutrition and Wellbeing Course Kings College London. www.susanchurchnutrition.co.uk/recipe-analysistraining/ 18th Sep - Recipe Analysis: Maximising Accuracy Nutrition and Wellbeing course Food Nation, Newcastle-upon-Tyne www.susanchurchnutrition.co.uk/recipe-analysistraining/ 28th Sep - Targeted Treatments for Cancers of the Digestive System The Education and Conference Centre, LondonSW3 6JJ www.royalmarsden.nhs.uk/education/ 30th Sep - Management of Chronic Kidney Disease Stage 4-5 - BDA Trainer London Road Community Hospital, Derby www.ncore.org.uk 30th Sep - Obesity Management - University of Nottingham School of Biosciences Modules for Dietitians and other Healthcare Professionals www.nottingham.ac.uk/biosciences NHDmag.com August/September 2015 - Issue 107
49
NHD Subscription 6 print and 10 digital issues Don’t miss out! Keep your professional development up-to-date with the UK’s favourite nutrition and dietetic magazine. k o.u .c BS JO 09 tic 20 te e ie c .d in w S w w
NHDmag.com
Issue 107 August/September 2015
• Latest dietetic and nutrition news • Feature articles on public health and community nutrition • Nutrition research updates from the world’s leading nutrition institutions • Clinical articles with practical features, case studies, guidelines and more
VITAMIN D IN PREGNANCY Cordelia Woodward p13
ISSN 1756-9567 (Print)
MALNUTRITION AND THE ELDERLY. . . p17
Anna FitzGibbon Prescribing Support Dietitian
PRETERM INFANT FEEDING NUTRITION AND CHYLOTHORAX DYSPHAGIA PRODUCT UPDATE COMMUNICATIONS IN DIETETICS
DIETETIC*/"3 s WEB WATCH s NEW RESEARCH
• Expert columns and comment from the coal face of UK dietetics • Career section with live jobs, events and courses
Subscribe online at nhdmag.com ONLINE
Visit www.NHDmag.com
CHEQUE
Please send cheque made out to NH Publishing Ltd to: NH Publishing Ltd, Suite 1 Freshfield Hall, The Square, Forest Row, East Sussex RH18 5ES
PHONE
Call 0845 450 2125 with credit card details to hand How to renew info@networkhealthgroup. co.uk for renewal link or phone above
Important notes: 1. NHD Magazine is a 10 issue per year frequency (6 print issues and 10 digital issues), combining the months of Dec/Jan and Aug/Sept. 2. Subscription fees are annual and not set per 12 issues. Magazine frequency may be subject to change 3. Discounted subscriptions are non-refundable.
Subscribing is easy at www.NHDmag.com
the final helping
Neil Donnelly
It was mid-morning and I was busy extracting the stone from a nectarine for my grandchildren and my mobile ‘pinged’. It was an email from NHD‘s Publishing Editor asking if I could get my column into her in the next day or two. The reasons for this request was that a small editorial group, including myself, are due to meet up next week and it would be helpful if the magazine was finished beforehand. Hmm! At this point, after cutting up the aforementioned nectarine into bite size pieces and putting them into the correct small individual personal coloured dishes for my grandchildren, I pondered the possibilities. We had left home at 6am that morning to travel down the M6 for two hours to look after the grandchildren for the day. This we do at least every two weeks. Looking after a three-and-a-half-yearold and a one-and-a-half-year-old for 10 hours (not counting debriefing) while their parents are working, requires at least two grandparents in our experience! However, I could have a quick read of the paper and see if there is anything that catches my attention for my Final Helping column. Something did:
Neil is a Fellow of the BDA and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders.
‘Researchers found grandparents overfed their grandchildren, giving them sugary snacks and drinks. Children cared for by their grandparents were twice as likely to be overweight or obese.’ I was then interrupted by my grandchildren both demanding another nectarine. Job done I returned to the article and found that it had been written by a
Professor at the University of Birmingham whose research had been conducted on parents of children in China! How interesting. However the thrust of the argument was that conflicting childcare beliefs and practice between grandparents and parents are felt to undermine efforts to promote healthy behaviours in children. Being a grandparent is fun, exciting, trying and sometimes tiring. Grandparents have a duty of care which goes something like, “Not on my watch”. When confronted by tears or tantrums, or sometimes “just as a treat”, one opts for an escape route. Whether this is a Mini Magnum, a packet of large chocolate buttons or a box of raisins, depends on the severity of the incident and the weather! A walk in the park/garden is always a good start to any grandparenting day, the activity somehow melts away any ’prick of conscience’ attributed to the ice cream or chocolate. In closing though, I then looked at a further study by researchers in Social Anthropology at Oxford University and published the previous month in Paediatric Obesity. They found that emotional support from grandparents has a protective effect against child obesity, even with the presence of other risk factors. Result. Come on kids, let’s get down to McDonald’s, but don’t tell your mum and dad!
NHDmag.com August/September 2015 - Issue 107
51
Low on calories, salt and fat. Big on taste. Introducing Nutritious & Delicious. A tasty new range of 13 meals, all under 400 calories.
674 – Chicken & Spring Vegetable Casserole
As the UK’s leading provider of nutritionally-balanced frozen ready meals, we’ve built our reputation on delivering good food to people who need it. Our new Nutritious & Delicious range calls on all this expertise to deliver tasty meals that contain less than 400 calories, are low in salt, fat and saturated fat, offer a good source of protein, and contribute to your patient’s 5 a day. With free delivery to the door, it’s perfect for patients in need of a carefully controlled diet at home. You look after the treatment. Let us look after the mealtimes.
Try our tasty ranges for FREE or request our brochures by calling
0800 066 3169 wiltshirefarmfoods.com