NHD Nov 2015 issue 109 by NH Publishing Ltd

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NHDmag.com

Issue 109 November 2015

paediatric food allergy Miriam Tarkin p13

ISSN 1756-9567 (Online)

Parenteral Nutrition on the Intensive Care Unit . . . p24

Pete Turner Nutritional Support Dietitian Royal Liverpool University Hospital

weight managEment dysphagia in care homes mycoprotein benefits ketogenic diet & alzheimer’s

dieteticJOBS • web watch • new research

REFERENCES: 1. Sampson HA et al. J Pediatr 1991;118(4):520-525. 2. Data on ﬁle. Abbott Laboratories Ltd., 2013 (Similac Alimentum case studies). 3. Borschel MW and Baggs GE. T O Nutr J 2015;9:1-4. 4. Koo WWK et al. J Am Coll Nutr 2006;25(2):117-122. 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. Date of preparation: July 2015 RXANI150117

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Contents

COVER STORY

Paediatric food allergy 6

News

41 Subscribe to NHD magazine

Weight management

42 Book review

Latest industry and product updates

The integration of dietetics and CBT

The Vitamin Complex

19 Clinical nutrition in care homes

44 Web watch

24 Critical care on the ICU

46 dieteticJOBS

30 Hydration

47 Events and courses

33 Sustainable protein sources

48 A day in the life of . . .

38 Dementia and nutrition

50 The final helping

Managing dysphagia

Parenteral nutrition

Drink scores

The benefits of mycoprotein

Ketogenic diet and Alzheimer’s disease

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 Alison Holloway, Specialist Community Dietitian Miriam Tarkin, Specialist Paediatric Allergy Dietitian Rosan Meyer, Paediatric Research Dietitian Carina Venter, Allergy Specialist Dietitian Kelly Fortune, Nutritionist Pete Turner, Nutritional Support Dietitian Majella O’Keeffe, Registered Dietitian Tim Finnigan, Research and Development Director Punita Mistry, Registered Dietitian Rachel Smith, Dietetic Support Worker

It’s easy online

NHDmag.com November 2015 - Issue 109

Online resources and updates

Latest career opportunities

Upcoming dates for your diary

. . . a Dietetic Support Worker

The last word from Neil Donnelly

Editor Chris Rudd RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Gillian White,Dietitian Publishing Assistant Katie Dawson Design Heather Dewhurst Routen, Nutritionist/Dietetics Assistant Charlotte Jennifer-Louise 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.

from the editor Welcome to the penultimate NHD before Christmas with a variety of articles for you, plus resources and updates, including Web watch which aims to keep you up to date with some of the relevant topics close to our work. 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.

Earlier in October, NHS England published Commissioning Excellent Nutrition and Hydration 2015-2018, which supports and guides commissioners in developing strategies to help prioritise excellent nutrition and hydration care in acute services and the community. It seems to be a practical guide, not only for commissioners, but also for the providers of the services that will hopefully encourage proactive dialogue and ultimately achieve the benefits of good nutritional and hydration care and reduce the consequences of malnutrition. If you have not seen this guidance yet, may I suggest you search it out! I feel that this offers hope and certainly a role for dietitians. Let me now tempt you with our articles. Patients with dysphagia will need to have a texture modified diet and fluids may need to be of a particular consistency. Kelly Fortune tells us of the multifactorial aspects of providing safe food for this patient group in Managing dysphagia in care homes. For some patients it may not be possible to access the gut or focus on enteral nutrition. Parenteral nutrition on the intensive care unit (ICU) by Pete Turner takes us on a journey covering when to use and start parenteral nutrition on the ICU, estimating requirements and what ‘ingredients’ make up the parenteral nutrition recipe. Punita Mistry provides an interesting account of Ketogenic diet and Alzheimer’s disease and concludes that more research into this may provide valuable answers. From the difficulties encountered with our ageing population to paediatric di-

etetics, as our cover story by Miriam Tarkin observes that ‘the field of paediatric food allergy continues to grow in these exciting times’. Miriam asks the question, What’s new in paediatric food allergy? And provides information on offering the most appropriate nutritional care and advice at the right time, whether it is breastfeeding, when to use particular infant formulas , weaning foods or full diet. The National Institute for Health and Care Excellence supports the use of the low FODMAP diet in IBS management. Good compliance to the low FODMAP diet hinges on the comprehensive patient education given. Should this education be on a one to one basis or delivered within a group session? In NHD Extra for our subscribers, Majella O'Keeffe reveals more in Group education and the low FODMAP diet. Experiences in practice written by Alison Holloway, informs us of a case study about the practical integration of dietetics and cognitive behavioural therapy in weight management. Want to know about sustainable protein sources? Then look no further than this issue of NHD! Emma Derbyshire provides us with the nutritional profile of mycoprotein, along with reviews of evidence in relation to its potential health and environmental benefits. Finally, after reading our articles and if you don’t like the idea of Christmas shopping, how about you sit down and write an article for next year’s NHD? We would like to hear from you… NHDmag.com November 2015 - Issue 109

news

Pre-pregnancy obesity and stillbirth risk

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

Rising body weights amongst women of childbearing age are a growing concern. Now, a new case-control study has looked at associations between body mass index before pregnancy and the risk of stillbirths. Data was analysed from 1829 singleton pregnancies from women living in Pittsburgh, US. The rate of stillbirth among lean, overweight, obese and severely obese women was 7.7, 10.6, 13.9, and 17.3 per 1000 live-born and stillborn infants, respectively, indicating that risk increased proportionally with body weight. Scientists further identified that placental diseases, hypertension, fetal anomalies and umbilical cord abnormalities were closely related to stillbirth amongst women with obesity and severe obesity. In summary, while there are multiple mechanisms underpinning a still birth, overweight and obese women should be aware that they may be at risk of health and medical complications that increase the risk of stillbirths. For more information, see: Bodnar LM et al (2015). American Journal of Clinical Nutrition. Vol 102 no 4 pg 858-64.

Dairy to reduce body fat levels?

A growing body of studies has looked at links between calcium and dairy consumption in relation to body weight and composition. Now, a new meta-analysis has collected the evidence in this area. Data from 41 studies (20 using calcium supplements) was analysed. Calcium intakes were around 900mg per day higher in the supplement groups. In the dairy group, calcium intake was around 1300mg per day. Overall, neither calcium supplementation nor dairy consumption led to reductions in body weight or fat. Further sub-analysis, however, showed that in the presence of energy restriction, dairy consumption led to significant reductions in body fat, but did not affect body weight. These are interesting findings indicating that dairy consumption (ideally around three servings daily) could lead to short-term reductions in fat loss when eaten as part of a weight management diet. For more information, see: Booth AO et al (2015). British Journal of Nutrition. Vol 114 Issue 07 pg 1013-25.

Past diets take a toll on telomeres.

Leukocyte (white blood cell) telomere length is a useful indicator of biological ageing, with shorter telomeres signifying faster ageing. Now, new work has looked at how certain dietary patterns could affect this. Dietary data using a semi-quantitative food frequency questionnaire was collected from a Korean sample of 1958 adults. Leukocytes telomere 6

NHDmag.com November 2015 - Issue 109

length was measured 10 years later on. Prudent (healthier) diets, i.e. those rich in legumes, nuts, fruits and dairy produce, were positively associated with longer telomere length in this cohort study. These are interesting findings, indicating that our past diets may catch up with us, possibly contributing to advanced biological ageing in our middle or older years. For more information, see: Lee JY et al (2015). European Journal of Clinical Nutrition. Vol 69 pg 1048-52.

news

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Metabolic syndrome (MetS) is a cluster of risk factors preced ing the development of Type 2 diabetes, heart disease and stroke. Screening for MetS is, therefore, an important indicator of future health. As the potential health benefits of the Palaeolithic diet (a diet resembling our ancient ancestors) has attracted much attention recently, one new meta-analysis has looked at this in relation to components of MetS. The new study published in the American Journal of Clinical Nutrition pooled data from four randomised controlled trials (RCTs) with a sample size of 159. Scientists concluded that Paleolithic diets led to short-term improvements in waist circumference, triglyceride levels, systolic and diastolic blood pressure, fasting blood sugar and HDL cholesterol, when compared with control diets. These findings imply that Paleolithic diets could go some way towards improving components of MetS. Further health benefits of Paleolithic nutrition are now worthy of investigation, along with additional RCTs that can feed into updated meta-analysis papers. Other work has looked into whether different protein sources, i.e. animal versus plant, could affect adults with MetS. Overweight adults (n=62) with MetS ate a healthy diet for two weeks at baseline and were then randomised to eat: 1) plant protein (18%; 2/3s plant sources), 2) animal protein (18%; 2/3s animal sources) or 3) animal protein (27%; 2/3s animal sources). All groups experienced similar weight loss benefits and reductions in MetS characteristics. These findings imply that either plant or animal protein could improve MetS profiles, although findings in this study were alongside heart-healthy, weight loss diets. For more information, see: Manheimer EW et al (2015). American Journal of Clinical Nutrition. Vol 102 no 4 pg 922-3 and Hill AM et al (2015). American Journal of Clinical Nutrition. Vol 102 no 4 pg 757-70.

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NHDmag.com NHDmag.com November 2015 - Issue 109

Weight management

Experiences in practice The practical integration of dietetics and cognitive behavioural therapy in weight management

Alison Holloway Specialist Community Dietitian, Sheffield Teaching Hospitals NHS Foundation Trust

for article references please email info@network healthgroup. co.uk or click here . . .

Alison has been an NHS Dietitian for over 20 years. Her primary interest is working with overweight patients with psychological and behavioural eating problems and who are struggling with traditional care.

I have been a dietitian for over 20 years and in that time, I have seen many changes in practice. One of the biggest has been the move away from a medical model of care, to using increasingly advanced counselling and motivational skills. I was fortunate enough to study for a year with Sheffield Hallam University on a foundation level 6 Cognitive Behavioural Therapy (CBT) course. The basis of CBT is looking at the interaction between thoughts, feelings, physical symptoms and behaviours, already an integral part of the dietetic role. Once I had completed this course, a job became available as a CBT Weight Management Dietitian for the new Sheffield Weigh Ahead service, which was a tier 3 weight management service. As this was a new service, there were opportunities to create novel ways of working. Supervision was available with the team psychologist to support the development of my CBT work. We agreed early on which patients would come to me and which to psychology, although there was overlap and transfer between us. My client group was primarily made up of those with a history of eating disorders or disordered eating, complex food behaviours and beliefs, emotional connections and emotionally driven behaviours around food and weight, needing dietary support alongside behavioural and emotional work. Although my patients were often suffering with depression and anxiety, I did not see patients for whom this was the primary issue with weight and eating, or who had other significant psychological or psychiatric disorders, such as personality disorders and psychosis.

NHDmag.com November 2015 - Issue 109

What quickly became clear was the complexity of this patient group, many of whom had not received any support that gave consideration to their psychological needs and the origins of their eating behaviours before. As a team, we developed a multidisciplinary assessment which included Gad-71, PHQ-92 and Rosenberg self-esteem scale3 alongside dietary assessment, physical activity assessment and social information. In addition to this, my initial assessment would include a basic formulation of the presenting problem, discussion about the wants and needs of the individual patient, confidentiality and boundary setting. I was able to see patients for 45-minute sessions weekly, for up to 10 weeks. A high proportion of patients had suffered loss, grief, or had been victims of crime or abuse. Supervision and a strong multidisciplinary team were essential in maintaining our own health and perspective in this role. One of my first cases in this new role was a sharp indicator of things to come. A patient whose obesity began with all their male relatives being murdered in the home. As a result, this patient, as a child, was fed by the mums, aunties and grandparents of the deceased relatives, as a treat and comfort. This had never been disclosed before, so previous healthcare professionals had gone down the route of eat less, exercise more and ‘why are you not complying’? This had served to increase the sense of guilt and failure of this otherwise very successful professional and unsurprisingly led to little success with weight control. There were some common themes and, over time, I developed a way of

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weight management

Active listening, gentle encouragement and nonjudgemental verbal and non-verbal language were key. working that seemed to fit this group of patients. Where is the evidence base? Well, there is a vast amount of evidence for CBT as a therapy, working with change and specifically to obesity and eating disorders; the key text that I began with was ‘The Cognitive Behavioural Treatment of Obesity’.4 Integral to this approach is building rapport. Obvious, I know, but this is a patient group with an often skewed view of health professionals, including dietitians. They bring with them a range of sometimes terrible experiences of how others have treated them because of their obesity. My experience at this point is of patients presenting with very closed body language (arms crossed is common), fear, tears and, in one memorable case, a ‘witness’! I learnt early on that time to draw out and listen to the patient’s own story of their weight and eating difficulties was a key part of truly understanding not only what was happening, but what had been tried before and how distressing this was for the patient as an individual. Active listening, gentle encouragement and non-judgemental verbal and non-verbal language were key. I never cease to be amazed by just how much people will confide in an initial appointment, to a complete stranger, if given the opportunity. A poker face was essential; this patient group are highly attuned to negative verbal and non-verbal cues in professionals. While listening, I would make notes, often in a simplified five areas template.5 A small cohort may be too scared at this point to tell their story, or even make any eye contact. If this is the case, I revert back to gentle open questioning. I ask patients to complete a journal, starting with their own goals and aspirations: weight, lifestyle or otherwise. I find it helpful to add thoughts and feelings, triggers or purges as appropriate to each individual. A common style I will use, especially with binge eating, compulsive eating or secretive eating, is to ask patients to record only what they feel is excess eating, so not ordinary planned meals, snacks or drinks; but binges, extra snacks and nibbles, extra portions and so on. This approach has proved very helpful in identifying those who feel that they binge, but in fact do not 10

NHDmag.com November 2015 - Issue 109

and in quantifying the amount and types of binge episodes. It is not unusual for patients to return for follow-up, having spotted trends in their own diaries and started to make changes after seeing the ‘extra’ eating clearly for the first time. Using the diary and assessment, I discuss and agree next steps with each patient individually. The types of changes we work on have common themes. Emotional eating, binge eating, habitual overeating, eating to please others, secret eating, eating as self-harm or, commonly, a combination. We usually agree a number of areas for change and then begin with those that the patient feels will be the easiest to manage. This can take some negotiation, as often patients will want to start with the most difficult problem first, or indeed change everything at once. Some have no idea where to start, as the prospect is simply too overwhelming. Often the starting point is uncomplicated habits such as a biscuit with a cup of tea or chocolate out of the machine at work. We aim to build a sense of hope and self-efficacy at this stage. Dietitians will be familiar with many of the treatment methods used. The use of distraction and alternative food choices, which can be just as valid with this group as any others, some further methods used include thought stopping, harm reduction, mindful eating, urge surfing, self-soothing and Helicopter view/perspective. The resource website www.getselfhelp.co.uk is invaluable in this work.5 Case Study A typical case was that of a 54-year-old lady who had gained weight through three pregnancies, tried Slimming World and Weight Watchers in the past, losing 1-2 stones and then regaining. At initial assessment she had a BMI of 41.77kg/m2, Rosenberg score 12, fruit and vegetable intake two/day and zero physical activity. This lady described a history of repeated bullying in her life from neglect in childhood through to domestic abuse in a previous relationship. We identified during assessment that this had led to low self-esteem and depression and

weight management this had impacted on her weight through a pattern of emotional eating and occasional binges. Previous attendance at commercial groups had increased her guilt and further reduced her self-esteem, as she felt unable to disclose her secretive emotional eating behaviour. Dietary assessment showed that she had started to reduce her portions, takeaways and eating out. She ate regular meals with low fat and low sugar choices. During binges and emotional eating she would eat large amounts of cake, biscuits and chocolate. She was knowledgeable about healthy eating and weight loss. Goals of treatment were agreed as improved understanding of the triggers for emotional eating and links with self-esteem, increased physical activity and weight maintenance. We began with psycho education about managing emotional eating, breathing techniques for anxiety and normalising responses to stress and distress. She completed an eating and emotions diary which we used to explore the triggers for emotional eating. We worked together to devise individualised strategies for difficult situations. Physical activity was encouraged and reviewed. At times during treatment, she was bothered by negative thoughts about herself and feeling ‘pressure’ to lose weight. We explored thinking about health in broader terms, moving the focus from weight alone, including positive self-esteem and mood. This approach led to increases in physical activity and reduction in emotional eating responses. This lady gained a much greater understanding of her use of food to manage emotions. She was able to reflect and felt much calmer and less critical of herself during difficult family stresses and was subsequently less likely to turn to food binges. Weight loss was modest, -1.5kg; however, she had significant increase in self-esteem, fruit and vegetable intake and physical activity. Rosenberg 25 (+13), fruit and vegetables 5 (+3), physical activity 200 minutes per week (+200). This lady was initially apprehensive about how we could help her, having focused on diet alone in the past. She was able to share her feelings about her low self-esteem and be open about her real problems with food. The sessions allowed us to get to the origins of her weight gain and the difficulties that she had in addressing them, rather than straightforward education which she neither

needed nor wanted. Increased confidence in herself then led to her being able to initiate physical activity and manage some very difficult times at home. It is crucial that we identify those patients for whom there are more complex underlying causes for the maintenance of their obesity. In this way, we have the potential to be able to create longerterm change. This case illustrated the benefits of not neglecting the wider definitions of health, in this case, as in many; overall physical and mental health was improved in advance of weight loss. Integral to this approach is looking holistically at all the aspect that affect a person’s choices around food and this often requires discussion and referral on, for example, for relationship counselling, stress management, mental health services, exercise on referral, alcohol and drugs services. I am clear that this is a lifelong process of managing overeating, much like any other chronic health condition. Ideally, ongoing support would be available as with other chronic syndromes. My experience is that most people are not ‘cured’, but that they can move the difficulties with food to a less prominent position in their lives. One of the key points I learnt from my experiences, was the value of having the CBT skills alongside extensive dietetic experience. This combination meant that I could adjust dietary treatments, at times moving away from standard practice, to allow a reduction in anxiety, guilt and failure by the patient. This gave me an advantage over our psychologists in managing treatment plans, especially for patients with conditions such as diabetes. An example would be negotiating an increase in oral hypoglycaemic agents with a patient’s GP to control their diabetes whilst they work on the psychological elements of their eating. Focusing away from low sugar, managed carbohydrate for a binge eater with diabetes, whilst they establish a regular eating pattern and physical activity. This approach does require a great deal of communication with other professionals, as, often, patients who I would be working with would leave enthused and feeling more in control, only for that empowerment to be crushed by a well-meaning professional reverting to standardised advice. The underlying philosophy of my work remains that: given the right approach, most people are honest about their eating difficulties: any progress in any area of health, is valuable. NHDmag.com November 2015 - Issue 109

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Cover story

What’s new in Paediatric Food allergy?

Miriam Tarkin Specialist Paediatric Allergy Dietitian and Dietetic Lead Miriam works at the Whittington Hospital in critical care and paediatrics and has been working on developing the Paediatric Allergy Service there over the past five years. She is the Secretary for the Food Allergy and Intolerance Group of the BDA.

Co-authors: Rosan Meyer and Carina Venter Rosan Meyer, Principal Paediatric Research Dietitian, Great Ormond Street Hospital and Research and Education Manager of the Food Allergy and Intolerance Specialist Group of the BDA Carina Venter, Allergy Specialist Dietitian, NIHR Post Doctorate Research Fellow, University of Portsmouth and Chair of the BDA’s Food Allergy and Intolerance Specialist Group

Over the last decade, a number of changes have been introduced to clinical practice guidelines and committee recommendations in the management of food allergy in children. Most recently, these changes have been in relation to the primary prevention of allergy.1 There is now a large body of evidence to guide us on how vitamin and mineral supplementation and other dietary factors, such as pre- and probiotics, given during the pre- and postnatal period, can influence outcomes of allergic disease.2 The addition of nutritional components to hypoallergenic formulas for both prevention of allergies and the induction of tolerance, have also been explored. This can often be a minefield for healthcare professionals and, as such, this article provides an update on the current recommendations and emerging research on nutrition and allergy in paediatrics to guide clinical practice. Allergy Prevention: Current guidelines

Due to the significant impact that food allergy can have on quality of life, morbidity and the financial implications from consultations and treatments, there has been great interest in the primary prevention of food allergy. It is thought that cows’ milk protein allergy (CMPA) alone has a cost of £25 billion to the NHS3 and is the leading cause of fatalities from food allergy in the UK.4 In 2014, following a systematic review, the European Academy of Allergy and Clinical Immunology (EAACI) published an evidencebased guideline to provide advice on

preventing food allergy, particularly for those at high risk of developing allergic disease.1 The recommendations are summarised in Table 1. Exclusive breastfeeding is recommended for all infants aged four to six months. If breastfeeding is insufficient or not possible, it is recommended that infants at high risk are given a hypoallergenic formula.1 These recommendations are supported by the Cochrane review on dietary prevention of allergic disease and food hypersensitivity in children.5 The EAACI guideline also states that there is no need to avoid introducing complementary foods beyond four months. With the exception of peanut (following the publication of the EAACI guidelines), there is insufficient evidence to provide recommendation about either withholding or encouraging exposure to potentially allergenic foods after four months once weaning has commenced, even if there is a family history of atopy.1 The EAACI guidelines are also in accordance with the American Academy of Paediatrics recommendations on the effects of early nutritional interventions on the development of atopic disease.6 Eating habits and the development of allergy and feeding behaviour

Healthy eating has been shown to reduce food allergy in infancy. In NHDmag.com November 2015 - Issue 109

PAEDIATRIC food allergy a recently published birth cohort study led by Grimshaw et al, it was shown that infants whose diets included high levels of fruits, vegetables and home-prepared foods, were less likely to have a food allergy by the age of two years compared to those with unhealthy diets.7 This study highlights the importance of giving healthy eating advice to all families during consultations, including those with children at high risk of developing food allergies. Another study published last month by Maslin et al, showed that young children consuming an exclusion diet for CMPA had higher scores for feeding difficulties, fussy eating and were slower to eat at mealtimes than those consuming an unrestricted diet up to 10 years after outgrowing their CMA.8 It is, therefore, important for children with CMPA to see a dietitian following diagnosis, to provide targeted guidance on weaning, including advice on texture, increasing variety and feeding behaviour.9 Children with CMPA should also be challenged as early as possible to assess tolerance

Table 1: Summary of recommendations for primary prevention of food allergy from EAACI food allergy primary prevention guideline1 Recommendations for all infants: • No special diet during pregnancy or the lactating mother • Excusive breastfeeding for four to six months • Introduction of complementary foods after the age of four months according to normal standard weaning practices and nutrition recommendations, for all children irrespective of atopic heredity. Further recommendations for high-risk infants: • If supplemental feeding is needed during the first four months, an approved hypoallergenic formula is recommended.

and progression of outgrowing their allergy, in order to prevent feeding difficulties later on. Hypoallergenic formulas

A Hydrolysed formulas for allergy prevention Hypoallergenic formulas may also have a role in the prevention of allergy. The 10-year

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NHDmag.com November 2015 - Issue 109

PAEDIATRIC food allergy Table 2: Extensively hydrolysed and amino acid formulas available on prescription in the UK Feed name

Manufacturer

Protein Source

SMA

Hydrolysed whey

Lactose content

Extensively hydrolysed formulas Althera Aptamil Pepti 1 Aptamil Pepti 2

Contains lactose

Milupa

Cow and Gate Pepti-Junior

Cow and Gate

Infatrini Peptisorb

Nutricia

Nutramigen 1 Lipil

Mead Johnson

Hydrolysed whey

Nutramigen 2 Lipil Pregestimil Lipil Similac Alimentum

Contains residual lactose

Hydrolysed casein

Lactose free

Amino acids

Lactose free

Abbott

Amino Acid Formulas Alfamino

SMA

Neocate LCP Neocate Active

Nutricia

Neocate Advance Nutramigen Puramino

Mead Johnson

German Infant Nutritional Intervention (GINI) study showed that intervention with partially hydrolysed whey and extensively hydrolysed casein formula in non-breastfed infants with a family history of allergy, led to a reduction in allergy disease, particularly atopic eczema/ dermatitis lasting up to 10 years of age.10 Two systematic reviews and three randomised control trials reviewed by EAACI in 2014, show evidence to suggest that extensively hydrolysed whey or extensively hydrolysed casein formula also have a protective effect in high risk formula fed infants.11

The range of hypoallergenic prescription formulas and commercially available cows’ milk substitutes that are accessible in the UK continues to increase. The prescription milks available in the UK are detailed in Table 2. In the last few years we have had the addition of Extensively Hydrolysed Formulas (EHFs): Althera (Nestle) and Similac Alimentum (Abbott) and Alfamino, an amino acid formula (AAF) from Nestle. There was also a recent name change from Nutramigen AA to Nutramigen Puramino (Mead Johnson).

B Hydrolysed formulas for management of CMPA An important role for dietitians is to provide support and education to other health professionals and General Practitioner’s on the hypoallergenic formula available and appropriate prescribing, particularly due to the economic burden that prescriptions of these formulas can present.2 Guidelines, such as those from the British Society of Allergy and Clinical Immunology and Milk Allergy in Paediatrics (MAP) (see Figure 1), can prove very helpful in the decision making for managing CMPA in both the breastfed and formula-fed infant.12,13

Peanut allergy is an increasingly global health problem, which affects between 1.0 and 3.0% of children in westernised countries.14 There is now evidence to support early rather than delayed peanut introduction during the period of complementary food introduction in infants. In the Learning Early About Peanut Allergy (LEAP) study performed at the Evelina children’s hospital, it was shown that consumption of peanut protein in high-risk infants (such as those with more severe eczema and egg allergy) can prevent peanut allergy.14 This study showed an 80% reduction in prevalence of peanut allergy in the

Nuts

NHDmag.com November 2015 - Issue 109

PAEDIATRIC food allergy

There is increasing evidence that disturbances in the gut microbial composition play a role in the pathophysiology of immune mediated disorders, such as food allergy. peanut protein consumption group (3.2%) compared to the avoidance group (17.2%).14 Following the results of the LEAP study, a consensus document on early peanut introduction and the prevention of peanut allergy in high-risk infants, was published by the World Allergy Organisation (WAO).15 Based on existing guidelines and LEAP trial data, this document provides guidance to assist the clinical decision making of healthcare providers regarding early peanut introduction. The guidance from this document advises that infants with early-onset atopic disease, such as severe eczema, or egg allergy in the first four to six months of life, might benefit from evaluation by an allergist or a physician trained in the management of allergic diseases. It states that clinicians can perform hospital peanut challenges for those with evidence of positive peanut skin tests to determine whether they are clinically reactive before home introduction is initiated.15 Further studies are required to identify the optimal age for introduction of other allergenic foods into the diet of high-risk of allergy or already allergic children, to look for ways to improve practice and prevent food allergy. We eagerly await the results of the UK Enquiring About Tolerance study (EAT) (www.eatstudy. co.uk), which is designed to test the hypothesis that repeated exposure to potentially allergenic foods (specifically wheat, sesame, fish, eggs and nut) through consumption at an early age, helps prevent food allergies in childhood. Pre-/probiotic debate

There is increasing evidence that disturbances in the gut microbial composition play a role in the pathophysiology of immune mediated disorders, such as food allergy.16 The concept that increasing prevalence of allergic disease has resulted from a lack of microbial stimuli during infancy and early childhood, is known 16

NHDmag.com November 2015 - Issue 109

as the hygiene hypothesis.16 As such, there is great interest in understanding the role that preand probiotics might play in the prevention and treatment of allergy. Probiotics are live bacteria that colonise the gastrointestinal bacteria and provide a health benefit to the host.17 Many studies have been performed on a variety of different probiotic strains on diverse paediatric at risk populations. Conflicting results have been found, which has made it difficult for guidelines to be formulated on their routine use for both prevention and allergy disease modification. These different findings may be related to the overall composition and nutrient content of the diet. However, preliminary evidence shows that Lactobacillus rhamnosus GG (LGG) may accelerate development of oral tolerance in cows’ milk allergic infants.18 Probiotics during pregnancy have also been associated with a reduced risk of eczema in high-risk infants.19 Despite this research, there is insufficient evidence at present to support a recommendation for the use of probiotics for the prevention or treatment of food allergy in routine practice and further research is required. Prebiotics are non-digestible food components that selectively stimulate the growth or activity of ‘healthy’ bacteria in the colon.20 There is some evidence that prebiotics (commonly oligosaccharides) added to infant feeds may prevent eczema and asthma in infants. However, a Cochrane review performed in 2013 indicated potential concern about the reliability of some of the prebiotic studies.20 As with probiotics, it is also early days before routine use can be recommend for prebiotics for the prevention of allergy and further research is required before they are recommend in routine practice. It is also important to determine which of the prebiotic and probiotic strains are suitable and for which patient population.1

PAEDIATRIC food allergy

Maternal intake of folate supplements during pregnancy may influence childhood immune phenotypes via epigenetic mechanisms. Vitamins and minerals

Other nutritional components have been investigated to assess their effect on the immune system. These include vitamin D, vitamin E, zinc and folate. The potential link between allergic disease and vitamin D emerged when it was identified that higher rates of allergic disease were observed in higher latitudes, where vitamin D deficiency is more common.21 A number of recent studies have examined the link between vitamin D and eczema. In several observational studies, lower serum vitamin D levels were associated with increased risk of eczema and skin barrier dysfunction in children.22,23 An association has also been found between low serum vitamin D levels and the diagnosis of asthma in children.24 The Department of Health (DoH) currently recommends vitamin D supplementation for: (a) all pregnant and breastfeeding women and (b) infants and young children aged six months to five years should have vitamin D supplementation.25 The DoH states that the infants who are formula fed do not need supplementation until they are receiving less than 500mls of formula.25 Several studies have examined dietary intake of vitamin E intake during pregnancy.25 A reduction in childhood wheeze has been associated with both maternal vitamin E and zinc intake.26,27 There were no significant results found for asthma, eczema or food allergy with maternal vitamin E intake.25 Maternal intake of folate supplements during pregnancy may influence childhood immune phenotypes via epigenetic mechanisms.28 Folic acid supplementation is recommended for all pregnant women to reduce the risk of congenital malformation. Current National Institute of Clinical Excellence (NICE) guidance recommends that health professionals advise all women who may become pregnant to take 400 micrograms daily before pregnancy and

throughout the first 12 weeks, even if they are already eating foods fortified with folic acid or rich in folate.29 There has been some conflicting evidence about folic acid in late pregnancy, with a possible increase in childhood asthma.30 Further research is required and there is no change in recommendation for the supplementation of folic acid in pregnancy. In summary

A significant amount of interest and research surrounds the prevention and treatment of allergy. Guidelines now exist for the primary prevention of food allergy. Exclusive breastfeeding continues to be strongly recommended. If breastfeeding is insufficient or not possible, an approved hypoallergenic formula is recommended for high-risk infants. In terms of the management of CMA, the number of EHF and AA formulas available in the UK continues to increase and it is important that we follow existing guidelines and educate other health professionals on these in order to ensure appropriate prescribing. Irrespective of atopic family history, normal standard weaning practice and nutrition recommendations remain unchanged for now for the introduction of complementary foods after the age of four months and delayed introduction of allergenic foods is not recommended. As we now know that there is an association between healthy eating and outcome of food allergy, it is important for health professionals to deliver healthy eating advice. In recent years, there have been great strides forward in the management of food allergy in paediatrics, making the role of the dietitian increasingly essential. The field of paediatric food allergy continues to grow in these exciting times. For article references please email info@networkhealthgroup.co.uk or click here . . . NHDmag.com November 2015 - Issue 109

Verbatim patient quote, Fresenius Kabi data on ﬁle – Thick & Easy™ Clear Acceptability Study Report Sept 2014

Simply restoring confidence Thick & Easy™ Clear is a gum-based drinks thickener that retains the natural appearance, taste and texture of fluids,1 and also ensures a consistent thickness over time. What’s more, Thick & Easy™ Clear: • Encourages fluid intake, meaning that patients can hydrate effectively while consuming drinks in their own time • Facilitates confidence to drink by reducing the fear of swallowing Contact us today on 01928 533516 or visit www.fresenius-kabi.co.uk and find out how we can help your patients rediscover a sense of normality. References: 1. Fresenius Kabi data on file – Thick & Easy™ Clear – Acceptability Study Report Sept 2014. ® Thick & Easy is a registered trademark of Hormel Health Labs. Fresenius Kabi Ltd is an authorised user. © Fresenius Kabi Ltd. October 2015 Date of preparation: October 2015 Job code: EN01141

Clinical nutrition

MANAGING DYSPHAGIA IN CARE HOMES

Kelly Fortune Nutritionist, at apetito Kelly works for apetito, a provider of meals to care homes across the country.

Between 50 and 75% of care home residents are thought to have dysphagia, which means that catering to residents with chewing and swallowing difficulties is a challenge that most homes face on a daily basis. The clinical term for difficulty swallowing and chewing food, dysphagia, occurs as a result of either nerve or structural damage which interferes with the safe movement of food and fluid from the mouth to the stomach. Signs of dysphagia include difficult, painful chewing or swallowing, dribbling or food spillage from lips and a sensation that food is stuck in the throat or chest, as well as a dry mouth, heartburn and changes in eating habits. Caused by a wide range of conditions, from strokes to degenerative illnesses such as dementia, dysphagia can have serious consequences. For example, if a resident suffering with chewing and swallowing difficulties is served food with an inappropriate texture for their particular stage of dysphagia, there is a risk of aspiration - where food or fluid is accidentally ‘breathed in’, potentially leading to aspiration pneumonia - and choking. There is also the emotional and psychological impact of not being able to eat normally. Risk of malnutrition

More than one million people over the aged of 65 are either malnourished or at risk of malnutrition.1 In fact, 41% of new residents are malnourished when entering a care home2 and, for those with dysphagia, ensuring that they get the nutritional intake they need to improve and maintain their health and wellbeing, can be particularly challenging.

Not only can eating become a very tiring process, the threat of the serious consequences described above can make mealtimes a fearful experience. Furthermore, for residents with dysphagia as a complication of dementia, the confusion and memory problems that arise can have a significant impact on appetite levels and their overall dining experience. Traditionally, dysphagia sufferers have been offered liquidised food, which can be unappetising and lacking in distinctive flavours. As water is usually added as part of the liquidising process, this dilutes both taste and nutrients, without contributing calories, vitamins or minerals. Each of these factors can contribute to an increased risk of becoming undernourished, which is why it is especially important to screen residents with dysphagia for malnutrition - both on admission to a home and on an ongoing basis. There are a number of screening tools available, but BAPEN’s ‘MUST’ tool is well recognised by the industry and is simple to use. As well as screening all residents for malnutrition, the first step in catering to residents with dysphagia is for them to NHDmag.com November 2015 - Issue 109

STAYING STRONG MEANS I CAN STILL PICK UP MY GRANDSON. 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 RXANI140256f

Clinical nutrition Table 1: Category E - ‘Fork Mashable Dysphagia Diet’ Food must be soft, tender and moist Requires some chewing Pieces of soft tender meat must be served no bigger than 15mms No skin, bone or gristle No sticky foods, e.g. cheese chunks, marshmallows Check before serving that no hard pieces, crust or skin have formed during cooking/heating/standing Table 2: Category D - ‘Pre-Mashed Dysphagia Diet’ Requires little chewing Has been mashed up with a fork before serving Usually requires a very thick, smooth (non-pouring) sauce, gravy or custard Should have no hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly bits Should have no skin, bone or gristle Meat must be finely minced - pieces approximately 2.0mms. Table 3: Category C - ‘Thick Purée Dysphagia Diet’ Cannot be poured Smooth throughout, requires no chewing Is moist Holds its shape on a plate or when scooped Can be eaten with a fork because it does not drop through the prongs No garnish Table 4: Category B - ‘Thin Purée Dysphagia Diet’ Can be poured Does not hold its shape on a plate or when scooped Requires no chewing Cannot be eaten with a fork because it slowly drops through the prongs The texture is not sticky in the mouth There are no loose fluids that have separated off

be assessed by a speech and language therapist, who can diagnose which stage of the condition they have reached. Guidelines for texture-modified diets

Residents with chewing and swallowing difficulties who require a texture-modified diet, must be served food that is safe for them to eat, which is determined by the stage of dysphagia they are experiencing. Recognising the difficulties faced in preparing texture-modified food, the National Patient Safety Agency created the Dysphagia Diet Food Texture Descriptors. These were

published in 2011 and replace previous versions that were developed by the British Dietetic Association and the Royal College of Speech and Language Therapists. Each Descriptor includes examples of how particular types of food should be prepared in order to be suitable for a resident at that stage of a texture-modified diet. This ranges from Category B, which can be described as a thin purée and is for those with more severe forms of dysphagia, to Category E. Described as ‘fork mashable’, food within Category E is for those in the early stages of dysphagia or in the final stages of returning to a ‘normal’ diet. NHDmag.com November 2015 - Issue 109

Clinical nutrition

Where needed, residents with dysphagia should be offered help to adopt the correct posture to encourage safe and comfortable digestion. As a very minimum, the Care Quality Commission requires all care settings to offer Category C and E meals to residents. As dysphagia is a journey that changes, it is very important that input from a speech and language therapist is sought on a regular basis to ensure that residents are given a diet that is fully appropriate for their stage. Tables 1, 2, 3 and 4 outline a few examples of what is required by each category. It is also important to note that, as the texture of food may change during the cooking/cooling process, consistency should be checked just prior to serving to make sure the dish is still fully compliant with the descriptors. For full details of the Descriptors click here . . . Fluids and medications may also need to be thickened for dysphagia sufferers, but it is vital to make sure care homes seek the advice of a speech and language therapist. The right appearance

Not only should texture-modified food meet the guidelines outlined by the Descriptors, the appearance of food is an important consideration, especially for residents with dementia who may become easily confused about what they are being served. Ideally, meals should be visually appealing and resemble the foods they are supposed to. While this can be difficult for care homes to achieve in-house, there are specialist food products available that include moulded options that look just like the food served to other residents. Support at mealtimes

Where needed, residents with dysphagia should be offered help to adopt the correct posture to encourage safe and comfortable digestion. Similarly, any help needed with eating and drinking should be available throughout the day.

Setting the scene for comfortable dining is of course important for all care home residents, but is particularly vital for those with dysphagia, so noise and interruptions should be kept to a minimum during mealtimes. Attractively set tables will help create a setting conducive to the enjoyment of food, but ‘fussy’ decorative touches can prove distracting - especially for residents prone to confusion, such as those with dementia - so presentation should be kept uncluttered. To minimise any isolation, dysphagia sufferers may experience at mealtimes, texturemodified meals should complement the menu options available to all residents. Summary

As dysphagia is a common side effect of conditions that typically impact more greatly on elderly people (such as those who have suffered a stroke, have dementia and Parkinson’s), catering to residents with chewing and swallowing difficulties is an ongoing challenge for care homes. Working with specialist providers of texture-modified meals is a useful means of serving residents options that closely resemble the dishes available to others, but regardless of whether dishes are prepared in-house or through an external supplier, adherence to the Descriptors means homes can be confident that residents with dysphagia are served meals that are safe for them to eat. As well monitoring for signs of undernourishment among all residents, dietitians should work closely with speech and language therapists, care home managers and caterers to ensure that residents with dysphagia continue to be served the most appropriate and safe texture suitable for their chewing and swallowing abilities, as well as food that is appealing and enjoyable to eat.

References 1 The Malnutrition Task Force www.malnutritiontaskforce.org.uk/about 2 BAPEN: Nutrition Screening Survey in the UK and Republic of Ireland in 2011

NHDmag.com November 2015 - Issue 109

Introducing our Softer Foods range. Helping people with dysphagia feel good about food again. Wiltshire Farm Foods: Delivering the right texture, flavour and appearance.

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critical care

Parenteral Nutrition on the Intensive Care Unit (ICU) Parenteral Nutrition (PN) has had a bad reputation on the intensive care unit with its use often being reserved for patients with complete gut failure. Enteral nutrition is seen as the gold standard for nutritional support and lack of success in establishing it is often seen as a failure by the ICU team. Pete Turner Nutritional Support Dietitian, Royal Liverpool University Hospital

Pete Turner is a Nutritional Support Dietitian at the Royal Liverpool University Hospital specialising in critical care, parenteral nutrition and intestinal failure. He is also Chair of the committee responsible for organising the BAPEN Annual Conference.

Recent studies have, however, suggested that this should not be the case and when given in appropriate amounts, at the right time, through the right access device, it is as safe and beneficial as enteral nutrition. Indeed, withholding it during prolonged failed attempts to establish enteral nutrition may result in increased mortality in malnourished patents. In 1998, Heyland published a metaanalysis of studies of PN in ICU and surgical patients.1 This compared standard therapy-iv dextrose and oral diet vs PN and reached the conclusion that PN should not be used on the ICU as it was associated with increased septic morbidity. Subsequent papers suggested that enteral nutrition (EN) was safer than PN2 and guidelines promoted the use of EN3 leading to a negative attitude towards PN. It is possible to explain the negative findings of the Heyland meta-analysis, as many of the studies included were carried out in the 1980s and 1990s when hyperalimentation was common and huge energy and nitrogen loads were given to metabolically stressed patients, possibly without the stringent line care that is often employed today. It is well accepted that most of the complications of PN, including hyperglycaemia, hyperlipidaemia, azotaemia and liver dysfunction, are due to overfeeding.4 In particular, hyperglycaemia in the days before intensive insulin therapy5 could be responsible for the poor outcomes and increased sepsis.6 Furthermore, the first generation lipids used in many of the studies were high in pro-inflammatory omega-6 fatty acids.

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More recent studies have shown that PN may actually be safer than EN in patients with questionable gut function7,8 and a 2005 meta-analysis found improved survival with PN in patients who could not be successfully fed enterally within 24 hours of ICU admission.9 In fact, this EN has almost certainly been dispelled by the CALORIES trial published last year.10 In this large scale trial carried out in 33 ICUs across the UK, 2388 patients were randomised to early EN or PN. There were no differences in outcomes, including infection rates and 30-day mortality between the two modes of feeding. Another particularly interesting finding was that around 50% of patients in both groups failed to meet their estimated energy target of 25kcal/kg, with the mean energy intake for each being around 20kcal/kg. This can lead us to the conclusion that if you avoid overfeeding, especially in the early stages of critical illness, the outcomes are the same for EN and PN. When to use PN

Although modern PN is safe, the general consensus from expert groups is that enteral nutrition should be used as the first line of feeding because of its protective effect on the gut barrier and its favourable influence on the gut associated lymphoid tissue (GALT) and immune function.11 It is an often overlooked fact that around 7080% of an adult’s immunological tissue is situated in the gut12 and the theoretical benefits of keeping it healthy should not be ignored. EN should, therefore, be used where possible and PN employed

quickly in patients with gut failure, including bowel obstruction, ischaemic bowel, short bowel syndrome and certain types of gastrointestinal leaks and fistulae. However, many patients on the ICU do not fit clearly into these categories and how quickly to start PN in patients with questionable gut function or poor tolerance of EN is a subject for debate. When to start PN

How early to start PN became particularly controversial when a study by Casaer13 recommended withholding PN for up to eight days in critically ill adults. In the ‘Early Parenteral Nutrition to supplement insufficient enteral nutrition in Intensive Care Patients’ (EPaNIC) study, 4640 ICU patients were fed as much enterally as possible and then randomised to early initiation of parenteral nutrition (day 2) or late (day 8) to meet a calculated energy target. The late initiation group showed improved outcomes with less infections, less cholestasis, fewer days of mechanical ventilation and renal replacement therapy, as well as a relative increase of 6.3% in the likelihood of being discharged from ICU alive. However, in this study, patients who were largely not malnourished were fed to a very high energy intake of up to 36kcal/kg/day in the early stages of their critical illness. Furthermore, patients who were most likely to benefit from PN, such as those with BMI <17kg/ m2 or those with short bowel syndrome, were actually excluded from the study. Many patients had diagnoses such as cardiac surgery suggesting that they could have been enterally fed if a more aggressive approach to their EN had been used. Indeed, the study protocol reveals that a very low gastric residual volume (GRV) threshold of 250mls was used to define tolerance to enteral feed, which is contrary to the recommendations of ASPEN11 who suggest EN should not be withheld for anything less than a GRV of 500mls. The EPaNIC study simply serves to reinforce our conclusions from previous studies: that feeding excessive amounts of PN to patients with a functioning gut who are not malnourished in the early stages of critical illness is associated with poor outcomes. In contrast, a Swiss study14, that carefully introduced PN at day 4 where EN was clearly not tolerated due to gut dysfunction, showed

improved outcomes. In a randomised study of 305 patients, indirect calorimetry was used to determine an energy target and PN initiated to supplement EN in achieving energy balance, alongside the maintenance of tight glycaemic control. Careful use of combined EN and PN without excessive energy provision to patients with gut dysfunction resulted in fewer infections, more antibiotic free days and shorter duration of mechanical ventilation. Braunschweig2 found that it was the particularly malnourished patients who benefited from use of PN. Even the aforementioned 1998 Heyland3 study supports its use in malnourished surgical patients. Thus, the evidence clearly supports cautious early introduction of PN on ICU, especially in malnourished patients with an element of gut dysfunction. Indeed, spending an excessive amount of time unsuccessfully trying to establish EN in this group of patients may be associated with increased mortality.2,8,9 ESPEN15 certainly supports this view, recommending that PN should be introduced after 48 hours of arrival on ICU if EN cannot be established. Estimating requirements

Three previously mentioned major studies10,13,14 have more or less confirmed that excessive energy provision in the early stages of critical illness is harmful. Failure to meet energy targets later has also been associated with poor outcomes.14,16,17 The ESPEN18 recommendation of 20-25kcal may give as good a starting point as any initially, although the very metabolically stressed or those at high risk of refeeding syndrome may NHDmag.com November 2015 - Issue 109

REFERENCES: 1. Huynh DTT et al. J Hum Nut Diet. DOI 10.111/jhn.12306 Published online 25th March 2015. 2. Data on file. Abbott Laboratories Ltd., 2007 (PaediaSure Plus & PaediaSure Plus Fibre taste testing). 3. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure Fibre taste testing). 4. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure & PaediaSure Peptide vs. Peptamen Junior Powder). *Independent, head-to-head taste testing for PaediaSure, PaediaSure Plus, PaediaSure Fibre, PaediaSure Plus Fibre and PaediaSure Peptide vs. Fortini or Frebini Energy or Peptamen Junior Powder Date of preparation: July 2015 RXANI150120

FEELING THE EFFECTS OF MEENA’S RECOVERY When a child is sick and malnourished, you just want to see them well again. PaediaSure’s full range of nutritional products supports them through the rough patch, and helps them get back to doing what kids do best.

• Oral nutritional supplements have been shown to increase total energy intake and improve nutritional status in at-risk children1 • PaediaSure offers a comprehensive range of products and styles to meet the needs of your patients • Children love the great taste*2-4

THE PAEDIASURE RANGE. HELPING KIDS BE KIDS AGAIN.

critical care need to start lower at around 10kcal/kg on day 1 as per the recommendations of NICE.19 Using kcal/kg is probably acceptable in many patients; however, it can under- and over-estimate at the extremes of BMI20 and is theoretically flawed at the extremes of age as you would be giving the same amount of energy to a 70kg 80-year-old female as to a 70kg 21-year-old male athlete, although their body composition is likely to be entirely different. Here, predictive formulae for basal metabolic rate (BMR) plus around 10-20%, have a theoretical advantage, with the Henry equation best representing the UK population. Use of an obesity adjusted weight for those with a BMI >30kg/m2 has been demonstrated to allow estimation of requirements closer to measured energy expenditure.21 Some dietitians prefer the use of ICU specific formulae such as the Penn-State equation; however, a recent study of 5672 patients found that there were no differences in mortality or time to ICU discharge alive for use of kcal/ kg and complex equations, including IretonJones, Mifflin-St Joel, Schofield and HarrisBennedict.22 It is important to realise that all predictive formulae just give an estimation of needs, especially when taking into account the difficulty in obtaining an accurate dry weight to use in them - most ICU patients are considerably oedematous following fluid resuscitation. Whichever method you decide is best for your patient group, regard this as just a starting point and monitor carefully for signs of overfeeding, such as hyperglycaemia and hyperlipidaemia, with appropriate modification of your energy prescription accordingly. Also be aware that patients require more when they are recovering, with ESPEN recommending an increase to 2530kcal in the anabolic (recovery) phase.18 Nitrogen (N) requirements are possibly one of the most controversial aspects of ICU nutritional support, with some authors suggesting that higher intakes are favourable23, especially in maintaining lean mass. However, a recent secondary finding of a large multicentre study24 was that the patients who received the most protein in the first week lost the most muscle mass, especially the more metabolically stressed. It would appear that very catabolic or immobile subjects are unable 28

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to utilise high protein loads24,25,26 especially to synthesise skeletal muscle and, therefore, it seems logical that nitrogen provision follows the same pattern as energy, with less being required at first and more in recovery. Consider following the recommendations of NICE19 and giving <0.16gN/kg in first few days and increasing to > 0.24gN in the anabolic phase. Signs that a patient is entering an anabolic phase include a drop in inflammatory markers such as C-reactive protein, resolving oedema, reduced hyperglycaemia and insulin requirements, plus the return of appetite and mobility. In addition, Bernstein suggested that a 40mg rise in weekly serial prealbumin levels indicates the switch to anabolism27. Optimum composition of PN

It is very important to consider the type of lipid used for ICU PN. It is almost certainly not optimal to use first generation lipids composed exclusively of soy bean oil, as these have long been associated with cholestasis, contain hepatotoxic phytosterols28 and are rich in omega-6 fatty acids which are the precursors of arachidonic acid and pro-inflammatory eicosanoids. Using second generation lipids where some of the soy bean oil is replaced with olive oil or coconut oil which is high medium chain triglycerides may have theoretical advantages; however, the third generation lipids containing anti-inflammatory omega-3 fatty acids from fish oil have been associated with improved outcomes on the ICU.29 Glutamine is a conditionally essential amino acid, with increased requirements in the critically ill. Parenteral supplementation of 0.3-0.5 g/kg has been shown to be safe and is associated with reduced septic morbidity, mortality and length of stay.30,31 Its use became extremely controversial following the REDOX32 trial and subsequent Canadian guidelines advising against giving it to critically ill adults.33 However, the REDOX trial has been criticised for giving a median dose of 0.78g/kg which is way in excess of that previously considered safe. In addition, both the enteral and parenteral routes were used in patients with a functioning receiving enteral nutrition. There is very little evidence to support the use of enteral glutamine, possibly because the GALT can synthesise glutamine from amino acids

critical care derived from the gut lumen. However, the use of parenteral glutamine should be considered in longterm ICU patients who are exclusively parenterally fed. Wischmeyer31 urged caution in septic patients, or those with multiple organ dysfunction syndrome (MODS); however, this recommendation was largely based on the excessive dose used in the REDOX trial. Previously, it was concluded that smaller doses of parenteral glutamine are likely to be beneficial in these conditions.34 Modern parenteral nutrition is safe to use on the ICU and may be associated with

improved outcomes including survival. It should be considered for all patients who cannot be established on EN within 48 hours of admission to the ICU, especially those who are malnourished. Avoid excess provision of energy and nitrogen in the initial stages and increase in recovery. PN can be used to supplement EN to ensure requirements are met while conferring the benefits of EN the gut. Third generation lipids containing fish oil should be strongly considered and those exclusively on PN for prolonged periods will most likely benefit from glutamine supplementation.

References 1 Heyland DK, MacDonald S, Keefe L et al (1998). Total parenteral nutrition in the critically ill patient: a meta-analysis JAMA16; 280(23): 2013-9 2 Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 2001, 74(4), 534-42 3 Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003 Sep-Oct; 27(5): 355-73 4 Klein C, Stanek G, Wiles C. Overfeeding macronutrients to critically ill adults: metabolic complications. J Am Diet Assoc 1998, 98(7): 795-806 5 Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in critically ill patients. N Engl J Med 2001 Nov 8; 345(19): 1359-67 6 Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE (2002). Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 87, 978-982 7 Griffiths RD. Is parenteral nutrition really that risky in the intensive care unit? Curr Opin Clin Nutr Metab Care 2004; 7: 175-181 8 Woodcock NP, Zeigler D, Buckley P, Mitchell CJ, MacFie J. Enteral versus parenteral nutrition: a pragmatic study. Nutrition 2001, 7(1), 1-12 9 Simpson F and Doig G. Parenteral vs enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive Care Med 2005, 31(1): 12-23. Epub 2004 Dec 9 10 Harvey S et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med 2014; 371: 1673-1684 11 McClave S, Martindale R, Vanek V et al (2009). Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Journal of Parenteral and Enteral Nutrition Vol 33 No 3 277-316 12 Furness JB, Kunze WA, Clerc N. Nutrient tasting and signaling mechanisms in the gut. II. The intestine as a sensory organ: neural, endocrine and immune responses. Am J Physiol. 1999 Nov; 277(5 Pt 1): G922-8 13 Casaer M et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365: 506-517 14 Heidegger CP et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet. 2013 Feb 2; 381(9864): 385-93 15 Pierre Singer, Mette M Berger, Greet Van den Berghe, Gianni Biolo, Philip Calder, Alastair Forbes, Richard Griffitths, Georg Kreyman, Xavier Leverve, Claude Pichard. ESPEN Guidelines on Parenteral Nutrition: Intensive care. Clinical Nutrition 28 (2009) 387-400 16 Villet S, Chiolero RL, Bollmann MD, Revelly JP, Cayeux RN MC, Delarue J, Berger MM. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr.2005, 24(4): 502-9 17 Strang R, Turner P, Shenkin A, Mogk M, Welters I. Nutrition and Trace Elements in Intensive Care Unit Acquired Weakness. Clinical Nutrition Supplements Vol 5 Supp 2 2010, 208-209 18 Kreymann KG, Beger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den Berghe G, Wernerman J, Ebner C, Hartl W, Heymann C, Spies C. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr 2006, 25(2): 210-23 19 NICE 2006 Clinical Guideline 32: Nutrition Support in Adults 20 Ava M Port and Caroline Apovian: Metabolic support of the obese intensive care unit patient: a current perspective. Curr Opin Clin Nutr Metab Care 2010, 13(2): 184-191 21 Cutts ME, Dowdy RP, Ellersieck MR, Edes TE. Predicting energy needs in ventilator-dependent critically ill patients: effect of adjusting weight for edema or adiposity. Am J Clin Nutr 1997, 66(5): 1250-6 22 Compher C, Nicolo M, Chittams J et al. Clinical Outcomes in Critically Ill Patients Associated With the Use of Complex vs Weight-Only Predictive Energy Equations. JPEN J Parenter Enteral Nutr 2014 23 Michele Nicolo, Daren K Heyland, MSc, Jesse Chittams, Therese Sammarco, Charlene Compher. Clinical Outcomes Related to Protein Delivery in a Critically Ill Population: A Multicenter, Multinational Observation Study. JPEN J Parenter Enteral Nutr 2015 Apr 21. pii: 0148607115583675. [Epub ahead of print] 24 Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Phadke R, Dew T, Sidhu PS, Velloso C, Seymour J, Agley CC, Selby A, Limb M, Edwards LM, Smith K, Rowlerson A, Rennie MJ, Moxham J, Harridge SD, Hart N, Montgomery HE. Acute Skeletal Muscle Wasting in Critical Illness. JAMA. 2013 Oct 16; 310(15): 1591-600 25 Biolo G, Agostini F, Simunic B et al (2008). Positive energy balance is associated with accelerated muscle atrophy and increased erythrocyte glutathione turnover during 5 wk of bed rest. Am J Clin Nutr 88, 950-8 26 Glover EI, Phillips SM, Oates BR, Tang JE, Tarnopolsky MA, Selby A, Smith K, Rennie MJ. Immobilization induces anabolic resistance in human myofibrillar protein synthesis with low and high dose amino acid infusion. J Physiol 2008 Dec 15;586 (Pt 24): 6049-61 27 Bernstein L, Bachman T, Meguid M. Prealbumin in Nutritional Care Consensus Group. Measurement of visceral protein status in assessing protein and energy malnutrition: standard of care. Nutrition 1995, 11: 169-71 28 Zi-Wei Xu and You-Sheng Li. Pathogenesis and treatment of parenteral nutrition-associated liver disease. Hepatobiliary Pancreat Dis Int 2012, Vol 11: 586 29 Edmunds CE, Brody RA, Parrott JS, Stankorb SM, Heyland DK. The Effects of Different IV Fat Emulsions on Clinical Outcomes in Critically Ill Patients. Crit Care Med 2014 Vol 42 No 5 1169-1177 30 Novak et al. Glutamine supplementation in serious illness: A systematic review. Crit Care Med 2002, 30, 2022-2029 31 Paul E Wischmeyer, Rupinder Dhaliwal, Michele McCall, Thomas R Ziegler and Daren K Heyland. Parenteral glutamine supplementation in critical illness: a systematic review. Critical Care 2014, 18: R76 32 Heyland D, Muscedere J, Wischmeyer PE, Cook D, Jones G, Albert M, Elke G, Berger MM, Day AG for the Canadian Critical Care Trials Group. A Randomized Trial of Glutamine and Antioxidants in Critically Ill Patients. N Engl J Med 2013; 368: 1487-95 33 Heyland D et al. Canadian Clinical Practice Guidelines. www.criticalcarenutrition.com/docs/CPGs%202015/4.1c%202015.pdf 34 Weitzel LR, Wischmeyer PE. Glutamine in critical illness: the time has come, the time is now. Care Clin 2010 Jul; 26(3): 515-25

NHDmag.com November 2015 - Issue 109

hydration

Drink scores

Review by Ursula Arens Writer; Nutrition & Dietetics

For references click here...

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

Advising people on a balanced diet is sometimes a complex instruction. People want to know the precise amounts and times of the day of the right foods and drinks for them; anything else just leads to randomness and muddle, and from that, a decline into chaos and anarchy (dietetically speaking). The current love of spread-sheeted information, and computer-cracked health scoring tabs and apps, fits in with the growth of self-monitoring appliances. Perhaps being able to selfscore and self-monitor diverse health behaviours, including food and drink consumption, may be the way to selfmotivate and self-remedy fitness and well-being. The only danger being that, as geeky whiz kids develop more computer algorithms, health professionals, such as dietitians, may no longer be needed. But of course not! Dietitians have unique insights and skills that no number crunching, bleeping-blinking computer could ever match. But there has been some interest in scoring foods and diets, with methods that bring new ways to assess and correlate intakes to disease risk and health outcomes. And numeric scores are what computers (and some people) like best. Kiyah Duffey and Brenda Davy from Virginia Technical University developed a way to score the healthiness of fluid intakes, published in the Journal of the Academy of Nutrition and Dietetics in July 20151. And the Healthy Beverage Index (HBI) is just the kind of tool so in-demand by software designers and app developers. What is the HBI and what does it show?

Score components relate to both amounts and nutritional quality of

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fluids consumed, with highest theoretical points being 100. Duffey and Davy describe fluid requirements as 1.0ml liquid for each kcal consumed and are calculated at 2000ml for typical US adults. Drinking at least these amounts of fluids per day, scores 20, with proportionately lower scores for lower amounts. Energy from fluids is also a generic factor, with less than 10% of total energy intakes scoring highest points of 20 and more than 15% scoring lowest points of 0. This seems a tight fit with minor fuzzy factor for major point differences. Then come the individual fluid component scores. Water (either tap or bottled) gains up to 15 points if at least 20% of requirements are consumed in this form, contrasting with 0 points if no fluid is consumed directly as water. The next highest scoring component includes sugar-sweetened beverages (SSBs). Of course, in the nutrition literature, this term has come to mean ‘fullfat’ versions of carbonated canned or bottled drinks, but it also includes any sugar containing dilutable squashes and syrups, fruit-flavoured drinks and sweetened teas or coffees, including the popular coffee-shop milk-shake style versions. Not consuming these items gives 15 points to the score; consuming more than 8.0% of total energy from SSBs brings the point score down to zero. Small 5-point units are gained by not consuming full-fat milk and further 5-point units come from consuming

hydration Table 1: Ursula’s two-day score Day 1

Day 2

Black tea, 750ml

Coffee plus soya milk, 300ml

Green tea, 250ml

Red wine, 350ml

Coffee plus soya milk, 300ml

Black tea, 250ml

Orange juice, 100ml

Total fluids: 1650ml

Total fluids: 1400ml

HBI score: 55

HBI score: 77

modest amounts of drinks, including unsweetened tea and coffee, low-fat milk or soya milk, diet drinks, pure fruit juice and alcohol. Exceeding modest amounts of these latter items brings the point score back down to zero. If your head is buzzing, it is because this is really information for a computer programmer, but what are the outcomes of this beverage scoring system? Outcomes

Duffey and Davy model different beverage diaries. A healthy one scoring the top 100 points, includes 1500ml from tap or bottled water, 750ml (three mugs) from black coffee or green tea, 250ml from skimmed milk and even includes a small (150ml) glass of red wine. From this selection, more than 2600ml of fluids are consumed, providing nearly 200kcals. The contrast is the ‘typical’ American beverage diary. Water provides only 250ml of fluid intakes. An equal amount comes from black coffee. Most fluid consumed comes from sodas, both standard and diet versions, and an additional 250ml comes from vanilla latte. This beverage diary provides 1700ml of total fluids per day and an energy intake of nearly 500kcals. The HBI score for the typical American beverage diary is 56 points. The average HBI score of US adults was assessed from National Health and Nutrition Examination Survey (NHANES) five-year data collected to 2010. Analysis from more than 16 thousand intake diaries produced a score of 63, slightly higher that the modelled typical beverage intake score of 56. Individuals with the highest HBI scores were those consuming most of their fluid intakes as water. While intakes of water were variable, the range of scores for intakes of SSBs and energy from beverages was even more variable (more than a 10-point

range), suggesting that these were the most challenging themes in trying to increase HBI scores in the US population. A random two-day score was calculated for the author (see Table 1). Scores were both lower (55) and higher (77) than for the US population score of 63. Total energy requirements were suggested by Dr Duffey to be a modest 1600kcals, so requirements for total liquid intakes were defined as 1600ml daily. The inadequacies of day one were no water intake, excess alcohol and excess energy intakes (due to the half-bottle of red wine). The inadequacies of day two were lesser, but still an indication of the challenge to achieve top scores: no water intake and inadequate total fluids consumed: 200ml short of the calculated requirement. While conceding shamefully to being a camel about drinking straight-water and preferring hot beverages for hydration, the HBI score system only allows a maximum score of 85 if water-pure is not consumed (even with lakes of tea). Duffey and Davy further assessed the association between the HBI and various makers of cardio metabolic risk from the NHANES data. Higher HBI scores (by at least a 10-point difference) were associated with better cardio metabolic measures: in normal-weight adults these were lower odds of having a high waist circumference, of hypertension and of having more favourable lipid profiles. In men specifically, there were also lower odds of having high C-reactive protein levels. Duffey and Davy concede limitations of their methodology, but suggest that the data supports some indications of adverse cardio metabolic health outcomes from fluid deficits. They propose refinements of the HBI to optimise measured and observed health associations. But, in any case, they advocate for US adults to drink enough tap or bottled water. NHDmag.com November 2015 - Issue 109

hydration The hydration index

Another index proposed for scoring fluids, is the hydration index. This has been developed by Dr Stuart Galloway at the Health and Exercise Science research group at the University of Stirling, and was presented at the 6th European Hydration Institute Meeting held in London this June2. Hydration efficiency of fluids consumed relates to volumes over time, of course, but also factors such as energy density of the fluid, electrolyte content and the presence of diuretic agents. In order to develop the hydration index, Dr Galloway investigated the effects on urine output and fluid balance of consuming one litre of 13 different drinks compared to the reference of still water. More than 70 willing male students participated in the drinking trials and they may have been especially keen on the day that a litre of lager was offered at breakfast. Urine outputs over four hours from fasted students were highest from the consumption of a litre of still water, and were similar for cola drinks, tea or coffee, lager, orange juice or sports drinks. Urine outputs were lower after intakes of a litre of oral rehydration solutions or of milk. Variations in caffeine content and sugars content

below levels of 10% had no influence on hydration index scores. What to drink for hydration?

Dr Galloway’s data supports the particular benefits of still water, but other typically consumed drinks scored nearly as well, including lager. Lower hydration index scores were demonstrated for milk and drinks with higher (above 10%) sugars content, and perhaps these choices should specifically be omitted from advice on effective hydration sources. There are many health and, perhaps, some cognitive benefits from consuming adequate amounts of fluids and, for most people most of the time, typical choices made provide adequate hydration. However, unintended excess energy intakes are a risk if most fluids consumed also provide calories, and keeping most fluid intakes energy-free is an important public health message - which runs counter to the many urgent advertising messages communicating that people (young men) seeking vigour need energy drinks. Water cannot be challenged as the pinnacle source of hydration, but many other drinks are nearly as good - and tea remains my personal choice of wet-stuff.

NHDmag.com . . .

. . . Your essential resource 32

NHDmag.com November 2015 - Issue 109

Sustainable protein sources

Mycoprotein: nutritional, health and environmental benefits There has been growing interest in the need to utilise alternative protein sources, given that world populations are expanding, yet there is limited space for sustainable agricultural production. Based on these changes, this article discusses the nutritional, health and environmental properties of mycoprotein, taking latest issues into context. Dr Emma Derbyshire PhD RNutr Independent Consultant (Public Health)

Tim Finnigan PhD

Dr Emma Derbyshire is a Nutrition Consultant who writes regularly for academic and media publications. Her specialist areas are public health nutrition and functional foods. Dr Tim Finnigan is director of research and development at Marlow Foods

Mycoprotein, the ingredient common to all QuornTM products, is a vegetarian protein produced inside fermenters by adding oxygen, nitrogen, glucose and minerals to a filamentous fungus known as Fusarium venenatum.1 Lord Rank first identified this rare but important fungus in the early 1960s when looking to find a micro-organism that could convert carbohydrate into proteins. This was during a time when there were concerns that population growth could lead to global food shortages and widespread famine.2 Now, more than five decades later, it seems that similar concerns are reemerging. There is renewed interest in sustainable protein sources due to rising demands for meat, fuelled by accelerations in population growth.3 In fact, demands for animal-based protein are estimated to rise by 72% between 2013 and 2050, which raises new concerns about the sustainability and environmental impacts of this.4 This article develops the knowledge about the nutritional profile of mycoprotein, reviews evidence in relation to its potential health benefits and brings in wider environmental perspectives. Nutritional profile

As shown in Table 1, when compared to other protein sources, mycoprotein is particularly low in energy, total and saturated fat while being high in fibre. The fibre found in mycoprotein is typically one-third chitin (poly n-acetyl glucosamine) and two-thirds β-glucan (as 1,3 and 1,6).5 From a health stance, for chitin fibre,

there is growing interest in its antioxidant, antihypertensive, anti-inflammatory, anticoagulant, antimicrobial, anticancer and antidiabetic properties.6 β-glucan, however, is thought to play a role in the regulation of appetite control, with its low glycaemic index and actions on gut flora being possible mechanisms behind this.7 With regard to the quality and digestibility of mycoprotein, the Protein Digestibility-Corrected Amino Acid Score (PDCAAS) is a measure of this. This has been reported to be 0.99 for mycoprotein, which is higher than values previously reported for soybean protein, beef, kidneys beans and lentils.8,9 Mycoprotein also contains all nine essential amino acids required by adults.10 Putting this into the context of European Commission nutrition claims, mycoprotein is: 1) ‘low in fat’, i.e. contains no more than 3.0 grams of fat per 100 grams of solids; 2) ‘low in saturated fat’, i.e. does not contain more than 1.5 grams of saturated fatty acids per 100 grams of solids and 3) ‘high in fibre’, i.e. contains at least 6.0 grams of Association of Official Analytical Chemists (AOAC) fibre per 100 grams.11 Mycoprotein also provides a spectrum of vitamins and minerals. Again, applying European Commission nutrient claims, mycoprotein falls under the category of being ‘high’ in zinc, phosphorous, manganese, copper, selenium and chromium and a ‘source’ of riboflavin.12,13 It is also low in sodium, containing 2.0 milligrams of sodium per 100 grams; equivalent to 0.005 grams of salt. NHDmag.com November 2015 - Issue 109

Sustainable protein sources Table 1: Nutrient density of mycoprotein compared to other protein sources (per 100g) Mycoproteina (wet)

Red meatb,c

Energy (kcals)

176

148

Protein (g)

21.2

8.08

NA NA

Carbohydrate (g)

Chickenb,d

Tofub,e

RNI12

1.2

1.88

Fat (g)

1.4 ‘low in’

10.0

6.32

4.78

Of which saturates (g)

0.3 ‘low in’

3.9

1.57

0.69

Fibre (AOAC) (g)

6.1 ‘high in’

0.3

Vit B1 (mg)

0.01

0.04

0.15

0.08

1.1

Vit B2 (mg)

0.23 ‘source’

0.15

0.21 ‘source’

0.05

1.4

Vit B3 (mg)

0.35

5.07 ‘high in’

7.48 high in’

0.20

Vit B6 (mg)

0.13

0.37 ‘source’

0.44 ‘source’

0.05

1.5

Vit B9 (µg)

200

42.5

350e ‘high in’

800

Chromium (µg)

15 ‘high in’

Copper (mg)

0.5 ‘high in’

0.07

0.09

0.19 ‘source’

1.0

Iron (mg)

0.5

2.24 ‘source’

1.09

5.36 high in’

Magnesium (mg)

375

Calcium (mg)

Manganese (mg)

6 ‘high in’

0.001

0.02

0.61 ‘high in’

2.0

Phosphorus (mg)

260 ‘high in’

184 ‘source’

209 ‘source’

700 2000

Potassium (mg)

100

321 ‘source’

251

121

Selenium (µg)

20 ‘high in’

16.6 ‘high in’

15.7 ‘source’

8.9 ‘source’

Zinc (mg)

9 ‘high in’

4.79

1.40

0.80

2.0

Sodium (mg)

Key: Data provided by Marlow foods (wet weight); Data extracted from the USDA database (for raw produce); Values for beef; 90% lean; Values for stewing meat; eRegular, prepared with calcium sulfate; (--) indicates no data; NA not applicable; RNI Reference Nutrient Intake. Values in bold meet European Commission (2008) nutrient claim guidelines. a

Mycoprotein and health

As shown in Table 2, a growing number of Englishlanguage papers, identified through Medline (Pub Med) have been published looking at the potential health benefits of consuming mycoprotein. Several have looked at the effects of mycoprotein consumption in relation to energy intake and satiety. For example, Bottin and colleagues (2012) looked at the dose of mycoprotein needed to induce satiety effects amongst 35 healthy overweight adults.14 After a period of fasting, the ingestion of 32 grams mycoprotein led to significant reductions in energy intake and increased feelings of fullness during an ad libitum lunch served at the end of the day.14 Similarly, work by Williamson et al (2006) and Turnbull et al (1993) found that the ingestion of mycoprotein preloads led to lower food intakes later in the day, when compared to eating chicken.15,16 One plausible mechanism could be the high fibre 34

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content of mycoprotein, with the viscosity of fibre in particular being thought to aid early signalling and enhanced feelings of satiation.17 With regard to blood lipid levels, Ruxton & McMillan (2010) conducted a six-week intervention trial on healthy free-living adults.13 It was found that, amongst subjects with higher baseline blood cholesterol levels, the ingestion of 88 grams of wet weight mycoprotein daily (dry weight equivalent to 21 grams QuornTM) led to significant reductions in total cholesterol levels.13 Similarly, earlier work found that mycoprotein consumption led to significant reductions in total and LDL cholesterol18 and improvements in high-density lipoprotein, when mycoprotein was eaten instead of meat amongst individuals with slightly elevated cholesterol levels at baseline19, as well as general reductions in serum cholesterol levels.20 Similar findings have also been reported elsewhere by Japanese scientists.21,22,23

Sustainable protein sources Table 2: Mycoprotein and health studies Publication

Study population

Health outcome

Study methods

Main findings Higher intakes of MYP i.e. 32g portions sig. ↓ EI and ↑ feelings of fullness (P=0.06) Insulin levels sig. ↓ 15, 30 & 45 minutes after eating 30g MYP. MYP sig. improved PPIR compared with whey protein (P=0.0165)

Bottin et al (2012)14

n=35 healthy overweight adults

Energy intake measured

Randomised laboratory study (seven occasions)

Bottin et al (2011)24

n=10 healthy overweight adults

Glucose control

Randomised laboratory study (two occasions)

Ruxton & McMillan (2010)13

n=21 healthy, free-living adults and n=10 controls

Cholesterol levels

Ate: 1) mycoprotein daily as QuornTM or 2) normal habitual diet for six weeks

Amongst subjects with higher baseline cholesterol levels, total cholesterol levels sig. ↓ after eating MYP daily

Williamson et al (2006)15

n=42 overweight F

Eating behaviour and hunger

Three-day controlled laboratory study

MYP had satiating properties that persisted for several hours after eating a meal

Two single-meal studies with crossover

Glycaemia was sig. reduced 60 mins after eating MYP vs. control. Insulinaemia ↓ after 30 mins and 60 mins after eating MYP vs control.

Turnbull & Ward (1995)25

n=19 healthy weight subjects

Glucose and insulin levels

Burley et al (1993)

n=18 healthy subjects

Appetite and satiety

Feeding trial

Turnbull et al (1993)16

n=13 female non smokers

Energy intake and appetite

Two three-day study periods

Turnbull et al (1992)18

n=21 overweight staff and students with slightly raised cholesterol levels

Turnbull et al (1990)19

n=17 staff & students with slightly raised cholesterol levels

Blood lipid levels

Three-week metabolic study

Udall et al (1984)20

n=100 subjects

Blood serum constituents

Two double-blind crossover studies

Blood lipid levels

Eight-week intervention study

After eating a lunch containing MYP (11g fibre) evening EI at an ad libitum test meal sig. ↓ by 18% vs control EI ↓ sig. by 24% on the day of the study and by 16.5% the next day after eating MYP vs control After eating 26.9g MYP (from cookies) total cholesterol ↓ by 0.95mmol/L in the MYP and 0.46 mmol/L in the control gp. LDL ↓ by 0.84mmol/L in the MYP and 0.34 mmol/L in the control. Differences were statistically significant After eating MYP instead of meat plasma cholesterol ↓ by 13%. LDL ↓ by 9% in the MYP gp and ↑ by 12% in the control. HDL ↑ by 12% in the MYP gp and↓ by 11% in the control. Differences were statistically significant. After 30 days there was a ↓ in serum cholesterol when 20g F. graminearium was eaten as cookies

Key: EI energy intake; gp group; HDL High-density lipoprotein; MYP mycoprotein; LDL low-density lipoprotein; PPIR Post-prandial insulin resistance;

↓ reduced, ↑ increased.

Other work has looked at markers of glycaemic control. For example, Bottin and colleagues (2011) found that mycoprotein, when eaten as a soup containing 30 grams mycoprotein, significantly improved post-prandial insulin resistance compared to whey protein amongst a sample of 10 healthy overweight adults.24 Similar findings

were also found by Turnbull & Ward (1995), when milkshakes containing mycoprotein were provided to a sample of normal healthy adults.25 While these results seem to indicate that mycoprotein shows promise as part of the dietary management of diabetes, randomised trials are now needed in clinical populations. NHDmag.com November 2015 - Issue 109

Sustainable protein sources Environmental

Feeding the world’s growing population will require a vast expansion in agricultural production by 2050.26 For example, whilst the world population was around 2.5 billion in 1950, this is projected to reach around 9.5 billion by 2050.27 Subsequently, one of the greatest challenges we face is feeding nine to 10 billion people while reducing the environmental impacts of this, i.e. greenhouse gas emissions, biodiversity loss and loss of ecosystem. Climate change is also predicted to make the situation worse, further threatening the amount of land available for rearing livestock.28 Innovative protein sources, such as mycoprotein based QuornTM offer one solution, potentially improving food security, as less land is needed to produce similar amounts of protein and energy.26 The consumption of vegetarian proteins has increased over the years due to rising concerns about animal welfare29, alongside animal diseases, economic changes, for religious (halal) reasons and now due to the global shortage of animal protein.30 Discussion

It can be seen that mycoprotein is a valuable food ingredient, providing high-quality protein while being low in total and saturated fat and high in fibre (chitin and β-glucan).5 Recent work has also shown that vegetarian and meat protein both appear to have a positive influence on appetite control and weight loss, influencing gut hormone profiles in a similar way.31 There has also been a general tendency to see mycoprotein first and foremost as a vegetarian food. However, changing demands for different sources of protein and the growing body of evidence supporting its health benefits, now mean that more people are turning to mycoprotein for different reasons. There has also been a tendency for the micronutrient profile of mycoprotein to be overlooked, yet it is an important source of zinc, phosphorous, manganese, copper, selenium, chromium and riboflavin. Including mycoprotein with the weekly diet may also help to keep meat intakes in check. For example, the UK Scientific Advisory Committee on Nutrition (SACN) advises that up to 500 grams of cooked red meat (approximately 70 grams daily) can be eaten daily, which falls in line with colon cancer prevention advice.32 While 36

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most people do not exceed these guidelines, males may benefit from substitution, as evidence from the UK National Diet and Nutrition Survey indicates that this population group has some of the highest meat intakes.33 For example, mean consumption has been reported to be 85g daily for males aged 19 to 64 years.33 Taken together, dietitians and health practitioners can play an important role in ensuring that their patients are aware of mycoprotein. As seen in the studies reviewed, mycoprotein has the potential to play a role in weight or diabetes management programmes, as well as helping to support a healthy lipid profile and subsequent heart health. The next stage is for randomised controlled trials to be undertaken in healthcare settings. Conclusions

In conclusion, mycoprotein should be recognised as more than a food option for vegetarians. This article has shown that mycoprotein provides good quality protein without being high in total or saturated fat. It is also high in fibre which is particularly important given that SACN (2015) guidelines have shifted fibre recommendations for those aged 16 years and over up to 30 grams of AOAC fibre daily.34 Mycoprotein also has the potential to improve the nutritional profile of patients’ diets, along with certain health outcomes. Research, in relation to satiety benefits, looks particularly promising and, on the whole, makes sense given the high fibrecontent of mycoprotein. Next, randomised trials in clinical settings are needed. Finally, innovative protein sources such as mycoprotein, appear to be one way forward given rising concerns about feeding the expanding world’s population. Given that QuornTM has been on the market since 1985, it already has a longstanding reputation of being safe. The next stages are to communicate the nutritional, health and environmental benefits of mycoprotein to patients and the lay public. Acknowledgement This work was supported by Marlow Foods Ltd, Stokesley UK. The content of the paper has been written independently. For article references please email info@networkhealthgroup.co.uk or click here . . .

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Dementia and nutrition

Ketogenic diet and Alzheimer’s disease Dementia can be described as a progressive syndrome caused by a variety of brain illnesses that affect memory, thinking, behaviour and the ability to perform everyday activities.1

Punita Mistry HCPC registered Dietitian, Royal Wolverhampton NHS Trust

Punita’s current role includes medicines management work, home enteral tube feeding and acute oncology. She is a member of the BDA group NAGE and Prescribing Support Dietitians Group.

Diet is thought to have an effect on the progression of symptoms and function. In recent years, there has been growing interest in using the ketogenic diet for Alzheimer’s disease. This article reports on recent research in this area and discusses the evidence for implementing the ketogenic diet in this patient group. It is believed that one in six people over the age of 80 have dementia and is estimated that only 59% of people living with dementia in England have a formal diagnosis. Alzheimer’s disease is the most common form and affects 62% of those with a diagnosis of dementia.2 With an ageing population and increased awareness of dementia, more people are being diagnosed than in the past. It is important to try to obtain a diagnosis for dementia in order to rule out other possible causes of any symptoms. It allows an explanation for any changes to behaviour and is also important so that any possible treatment and support for individuals and their families or carers can be accessed. Since 2010, the UK government has committed to increasing research funding into dementia.3 However, a recent study concluded that even though this has improved, funding for research into dementia is still disproportionately low against disease burden compared to other diseases such as cancer and coronary heart disease (CHD). Dementia has the highest social care system cost of £10.2 billion per year compared to cancer and CHD. Despite this, in 2012, for every £10 in health and social care cost of disease, cancer received £1.08 in research funding, CHD received £0.65,

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compared to dementia which received only £0.08.4 Given disease burden, it is important for research to be carried out in this area. As a degenerative disease, if there are potential methods of reducing the rate of disease progression, then these should be investigated. What is a ketogenic diet?

A ketogenic diet is a diet which results in ketone bodies being produced as a result of the body having to use fat as an energy source instead of carbohydrate. The exact composition of this diet can vary, but it is generally based on a high fat, low carbohydrate and adequate protein intake. The classical ketogenic diet uses a 4:1 ratio in calorie intake of fat to carbohydrate.5 Variations, or less restrictive versions of this, include the modified Atkins diet, medium chain triglyceride diet and low glycaemic index treatment.6 In normal energy metabolism, the brain uses glucose as a primary energy source. However, a high fat and low carbohydrate intake results in fat being broken down in the liver to fatty acids and ketone bodies. This also happens during prolonged periods of starvation or fasting, when alternative energy sources are needed. The ketone bodies can then be used instead of glucose by the brain.7 It has been found that once ketone bodies reach a concentration of 4.0mmol/L, they are used as an energy source by the central nervous system.8 The ketogenic diet has shown to be effective in treating refractory epilepsy and has been used in this area for many years.5 Although it appears that the ketogenic diet is beneficial in seizure

The ketogenic diet has shown to be effective in treating refractory epilepsy and has been used in this area for many years. Although it appears that the ketogenic diet is beneficial in seizure control, there are potential weaknesses . . .

control, there are potential weaknesses; 30% of participants reported short-term gastrointestinalrelated adverse effects and compliance with the diet was poor, with only 10% remaining on the diet for three to six years.5 Evidence for ketogenic diet in Alzheimer’s disease

Research into the use of the ketogenic diet for neurodegenerative conditions, including Parkinson’s disease and motor neurone disease, is growing. Unfortunately, there is little evidence for the use of a ketogenic diet for Alzheimer’s disease, particularly in human trials. Current evidence is based on animal studies, but this appears to be conflicting. Studies using Alzheimer’s disease in mice that were fed a ketogenic diet have shown improvements in motor function9 and a reduction in β-amyloid levels (which form the plaques associated with Alzheimer’s disease).10 In canines, however, effects were limited to the parietal lobe only.11 Although there is little evidence of the benefits of the classical ketogenic diet in humans, a less restrictive form of the ketogenic diet, such as the modified Atkins diet which would contain higher amounts of carbohydrate and protein intake compared to the classical ketogenic diet, could be a more realistic strategy to use and could improve compliance. Using the modified Atkins diet has been shown to be effective for children with epilepsy12 and so it could be as equally effective as the classical ketogenic diet for Alzheimer’s disease.

To minimise compliance issues, an alternative method of inducing ketosis, by using a ketone monoester alongside normal intake, has been investigated. It was shown to improve cognitive performance and reduce amyloid-β and tau deposition in a mouse Alzheimer’s disease model.13 A study which observed the effect of taking a ketone monoester supplement in one participant with Alzheimer’s disease concluded that using this method is safe, convenient and can be taken regularly as a food supplement with no difficulty. It resulted in the participant with early onset Alzheimer’s disease improving from needing constant supervision to becoming more self-sufficient (within days) and carrying out more complex tasks, such as housework and gardening, by six weeks. He was also able to discuss events that had taken place the previous week.14 During this 20-month study, the participant’s brain MRI was stable. Unfortunately, these effects were limited and he eventually deteriorated and also showed poor wound healing, respiratory infection and an outbreak of fever. Despite his poor outcome, this case study did show that not only did the ketone monoester slow down progression, but it also temporarily reversed some symptoms of Alzheimer’s disease. A stronger evidence base perhaps, including randomised controlled trials, is needed before these results can be generalised. NHDmag.com November 2015 - Issue 109

Dementia and nutrition

. . . we need to question the use of a restrictive diet in a group that may be facing existing nutritional issues. Mechanism of action

The mechanism through which a ketogenic diet improves symptoms of Alzheimer’s disease is unclear; however, it is believed that it provides a neuroprotective effect. It has been shown in animal models (mice) that a ketogenic diet resulted in improved mitochondrial function and less oxidative stress and β-amyloid deposition compared to those fed a normal feed.10 Cognition and alertness has been shown to improve with patients who are on a ketogenic diet for epilepsy15, which was thought to be due to improvements in seizure control, decreased medication, or a nonspecific effect of the diet. Another study found that attention and social function improved in children with epilepsy.16 Therefore, although there is a lack of evidence for the use of the diet in humans with Alzheimer’s disease, there is evidence which demonstrates an improvement in cognitive function from following the ketogenic diet. The question that arises is whether it would result in a significant improvement in symptoms of Alzheimer’s disease and at what stage of the disease would the diet need to be implemented in order to have a beneficial effect in slowing down the rate of progression of disease. Practicality of implementing a ketogenic diet in this patient group

Although the evidence base for a ketogenic diet in this population is still building, the reality of being able to follow this diet in this patient group is another challenge altogether. Firstly, there is the issue of gaining informed consent to implement this diet, which may be difficult depending on what stage of dementia the individual is at. If an individual is confused, or if they are unlikely to remember or understand why their food choices have been restricted, then it may cause them unnecessary distress. A further challenge is the actual implementation of the diet. This may vary depending on where the individual is living. For example, it may be easier to implement if the individual is within 40

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a care setting and all meals are being catered for. However, it would require appropriate training for staff in care homes. If an individual is living in their own home and family members are caring for them, then they would require dietetic advice for a ketogenic diet. If an individual was still managing to prepare their own meals, it may be difficult to implement a change in their diet at a time when routine is key. If memory has been affected, then trying to remember new information will be difficult. More importantly, we need to question the use of a restrictive diet in a group that may be facing existing nutritional issues. It is common for individuals with Alzheimer’s disease to have a poor appetite, not recognise hunger or thirst, suffer from disease-related malnutrition, have difficulty chewing or swallowing, and, therefore, any restrictions to their food choices could have a further impact on their nutritional status. Maintaining nutritional status is usually a priority in this patient group. When considering malnutrition and the use of energy dense diets for people with dementia, the ketogenic diet would at least coincide with this, as both are based on a high fat intake. It would be important to assess people at an individual level to determine what the nutritional priority and the dietetic aim is and how appropriate the ketogenic diet would be for them. Overall, there is limited evidence for the use of a ketogenic diet for Alzheimer’s disease at present. More importantly, it is restrictive in a patient group that may already be facing nutritional issues. Familiar foods, nutritionally dense foods and maintaining nutritional status should remain the priority for people with Alzheimer’s disease. However, we cannot ignore the potential for the diet to improve quality of life. It would be beneficial for the effects of the ketogenic diet to gain more research funding and it would be interesting to observe the potential future for its use in neurodegenerative disorders. For article references please email info@networkhealthgroup.co.uk or click here . . .

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book review

The Vitamin Complex Our obsessive quest for nutritional perfection

Review by Ursula Arens Writer; Nutrition & Dietetics

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

By Catherine Price Oneworld Publications, 2015 ISBN 978-1-78074-346-2 Price: £11.99

If you are in a hurry, the conclusion of this review is, a MUST READ book for dietitians. But perhaps you have time to linger and consider further why this is such an excellent book. The hugely annoying factor is just that Catherine Price is not a nutrition professional, but has managed to dig deeper, consider wider, communicate more clearly and conclude more pragmatically than many colleagues who are more learned in this terrain. She is a disciple of Michael Pollen who is well known as a prolific and influential food policy communicator, but Catherine Price has steered more into the sciency-bit of food debate (the home of dietetics). Catherine discusses the history of vitamins, the economic and policy debates of vitamins, the latest health research on vitamins, the confusions both planted and accidental around vitamins, the industry and consumer pushes and pulls around supplementation and the legislative and political inputs on vitamin use. There is massive interweaving of all of these aspects and all contribute to the high alertness of consumers and industry to these ‘magic bullets’ that promise health and wellbeing, to counter the damages of sedentary lives and conveniencedriven food choice. Catherine is always cool and rational in her discussions and yet there is enough pepper and spice in the illustrations she selects, to make this a very exciting read. The topics are all well known to dietitians and yet there

NHDmag.com November 2015 - Issue 109

are so many new and astonishing aspects to Catherine’s insights on vitamins, that a huge ‘fortification’ of understanding is guaranteed. For a tiny taster of the contents of this book, let’s start at the very beginning: with the letter A. Vitamin A is widely available from many natural and fortified food sources in the UK diet, but deficiency is still a global problem causing blindness and fatal outcomes from impaired immune responses to diseases such as measles. Night blindness precedes dry-eye and ulceration of the cornea and, yet, even if it never develops to the severe stages, it is a major handicap in societies without the illumination provided by electricity. Seeing children become fully dependent on others after sunset - estimated to affect more than 130 million preschool children and it is common enough to be considered a normal part of late pregnancy in some poorer communities - estimated to affect more than six million pregnant women annually. Historical descriptions of sailors’ blindness were evidently due to vitamin A deficiency, but were tagged to causes as random as homesickness or humidity or masturbation. Treatments for afflicted sailors were bizarre, although being locked in a dark closet, ‘to give the eyes a rest’, was perhaps less painful than other common maritime remedies for ill health.

book review

. . . I give this a 10/10 rating and urge dietitians to put aside ‘140-character reading’, and read the 380 pages of this book. Catherine interviewed vitamin A expert Alfred Sommer about his battles to combat deficiency in Indonesia. His initial suggestions to dose vitamin A orally were mocked by WHO experts, who supported the evidence-based strategy of injections. The critics said that children would spit out capsules, and that, ‘patients liked injections’. The strong associations between night blindness and mortality rates led Sommer to consider that it was a late rather than an early indicator of vitamin A deficiency, and his study of 26 thousand children published in 1986, demonstrated that giving one vitamin A capsule every six months resulted in the 34% reduction in death rates in deficient children. Catherine describes Alfred Sommer as a feisty expletivefilled New Yorker, who can now take ‘I-toldyou-so delight’ that vitamin A supplementation programmes are viewed as the single most costeffective intervention in modern medicine and are being funded by UNICEF in more than 70 countries. Shipping pills between and around countries cannot be the solution to vitamin A deficient populations (although the DSM-funded Sight and Life vitamin A supplementation programme deserves high praise). Beta-carotene to vitamin A conversion rates have been re-assessed in the last two decades, with dramatic changes for policy. Pure beta-carotene in oil has a conversion rate to vitamin A of about two to three, but assessments for typical American diet rates were increased from six to about 12; Sommer estimates that conversion rates in typical Indonesian diets are lower still at about 24, half those in typical American diets. The lower conversion rates explained the greater vitamin A deficiency rates observed in some populations, where theoretical diet calculations predicted adequacy. New focus on food-first strategies has led to developments of bio fortification and, specifically, genetic-modification. The story of ‘Golden Rice’ is for now, just a story. The insertions of daffodil

genes into rice that made it a beta-carotene source was announced in 1999 and there was excitement that this was the first genetically engineered crop that offered direct benefits to consumers rather than only farmers. But there was opposition. A huge amount of golden rice would need to be consumed to meet daily vitamin A requirements, and the involvement of the biotech company Syngenta increased opposition from food activists. Fifteen years later, field test trials of an even higher carotene variant of golden rice were successful and Syngenta declared ‘free use’ of the product to farmers whose direct annual profits from rice were less than 10,000 US dollars. But there is still not a single grain of commercially produced golden rice on the market because of fundamental opposition to the technology. Catherine observes huge hypocrisy and ‘nutritional blindness’ from the well-fed supplement-taking populations of the US in relation to a technology that could contribute dramatically to reducing vitamin A deficiency in suffering populations. On this topic, Catherine has given a “yes” to a strategy that she feels can challenge the 500 thousand vitamin A-deficient children going blind each year. Many of the descriptions in this book are based on the American marketing and legislative developments of vitamin use. There is a whole sorry chapter on how the Food and Drug Administration (FDA) was humiliated and politically outmanoeuvred in relation to the ‘Dietary Supplement Health and Education Act (DSHEA)’ passed in 1994 - for fear of being thought even more bizarre. I will not reveal that this was my favourite chapter. I could go on and on presenting cherries of detail from this information feast of a book. But rather, I give this a 10/10 rating and urge dietitians to put aside ‘140-character reading’, and read the 380 pages of this book. It is a deeply satisfying masterpiece of nutrition science writing. NHDmag.com November 2015 - Issue 109

web watch

web watch Online resources and useful updates. Research prioritisation: workshop reports Public Health England has published five reports from workshops held to prioritise research needs in dementia, obesity, best start in life and evaluation of public health interventions: www. gov.uk/government/publications/ research-prioritisation-workshopseries Commissioning nutrition and hydration care NHS England has published Guidance - commissioning excellent nutrition and hydration 2015-2018. This document provides guidance on commissioning and provides examples of approaches that can be adopted locally to improve the nutrition and hydration care of the population in acute services and the community. It also outlines why commissioners should make this issue a priority - how to tackle the problem, how to assess the impact of commissioned services and highlighting the work which is already underway. www.england. nhs.uk/commissioning/nut-hyd/ Measuring child development The Department of Health has updated its guidance Developing a public health outcome measure for children aged 2 – 2½ using ASQ-3. Originally published in January 2015, this update includes information on how to submit data on the child development indicator to HSCIC and about the introduction of the ASQ Social and

Emotional questionnaire. www. gov.uk/government/publications/ measuring-child-development-atage-2-to-25-years

Alternative guide to mental health care in England The King’s Fund has published an animation illustrating the different mental health services available and how they fit in with other health services. Whilst demonstrating the range of services available, it also highlights some of the issues that need to be addressed. www. kingsfund.org.uk/audio-video/ alternative-guide-mental-healthcare-england Dental caries and obesity in children Public Health England has published The relationship between dental caries and obesity in children: an evidence summary, exploring whether dental caries and obesity are found in the same individuals and populations. The report reviews and summarises what is currently known and supports the dental public health and obesity teams. www.gov.uk/government/ publications/dental-caries-andobesity-their-relationship-inchildren Ageing and health The World Health Organisation has published World report on aging and health. This report outlines a framework for action to foster healthy ageing built around the new concept of functional ability.

NHDmag.com November 2015 - Issue 109

Making these investments will have valuable social and economic returns, both in terms of health and wellbeing of older people and in enabling their ongoing participation in society. www.who.int/ mediacentre/news/releases/2015/ older-persons-day/en/

0-5 Children’s public health transfer The Local Government Association has published Must knows: Children’s public health transfer. It details councils statutory responsibility for commissioning children’s public health services for children aged 0-5 following the transfer of these responsibilities from the NHS on 1 October 2015. This joins up with the much larger transfer of public health functions to local government which included responsibility for 5-19 year olds, which took place on 1 April 2013. www.local.gov.uk/web/ guest/publications/-/journal_ content/56/10180/7505714/ PUBLICATION Inflammatory bowel disease audit The Royal College of Physicians has published the fourth inflammatory bowel disease (IBD) clinical audit report. The report reveals that the majority of patients (80% adult and 77% paediatric) with Crohn’s disease saw an improvement following biological therapies. The purpose of this audit is to measure the efficacy, safety and appropriate use of the biological therapies infliximab and

web watch adalimumab, in patients with IBD in the UK. The audit also aims to capture patients’ views on their quality of life at intervals during their treatment. www.rcplondon.ac.uk/press-rele ases/latest-uk-ibd-audit-reportshows-further-improvementpatientsNAO guide to the Department of Health The National Audit Office is publishing a suite of short guides, one for each government department. A short guide to the Department of Health is designed to provide a quick and accessible overview of the Department and focuses on what the Department does, how much it costs and recent and planned changes. www.nao.org.uk/wp-content/ uploads/2015/09/A-Short-Guideto-the-Department-of-Health.pdf

Resources from Nice Nice guidaNce NICE has published the following guidance: Type 1 diabetes in adults: diagnosis and management. NICE guideline (NG17). www.nice.org.uk/ guidance/ng17 Diabetes (Type 1 and Type 2) in children and young people: diagnosis and management. NICE guideline (NG18). www.nice.org. uk/guidance/ng18 NICE Shared Learning Database: dietetic-led coeliac service NICE has added ‘A dietetic-led coeliac service incorporating group education’ to its Shared learning database. This example describes Gloucestershire Hospitals NHS Foundation Trust service redesign to increase patient capacity within existing dietetic provision,

whilst also aiming to improve service quality. www.nice.org. uk/sharedlearning/a-dieteticled-coeliac-service-incorporating - group-education NICE guidance: coeliac disease NICE has published guidance Coeliac disease: recognition, assessment and management (NG20). This guideline covers the recognition, assessment and management of coeliac disease in children, young people and adults. It updates and replaces NICE guideline CG86 and includes recommendations on: referral of people with suspected coeliac disease; information and support; advice on dietary management; non-responsive and refractory coeliac disease; and monitoring and review in people with coeliac disease. www.nice.org. uk/guidance/ng20

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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 - £29,151 to £38,411pa (depending on experience). Now is your opportunity to sample the Mediterranean way of life in Gibraltar. 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 to cover a period of maternity leave. To discuss any aspects of the post, please contact Ms Katrina Skilton, Senior Dietitian on 00350 2007 2266 ext 2199 or email katrina.skilton@gha.gi Application packs can be obtained from the Recruitment Section on 00350 2007 2266 ext 2082, Fax: 00350 2004 3864 or email: kevin.galliford@gha.gi Closing Date: Friday 6th November 2015

SPECIALIST BARIATRIC DIETITIAN - PHOENIX HEALTH, LIVERPOOL - £32,000- £36,000 (+ Benefits) Contract: 37.5 hours per week, 12-month fixed-term contract. Phoenix Health is a highly specialised and experienced provider of weight loss surgery founded and led by doctors. We are recruiting a Specialist Bariatric Dietitian to join the team at Aintree Hospital in Liverpool, which can include travel to Phoenix Health’s other locations in Chester, London, Manchester and Belfast. Key duties include: Pre- and postoperative assessment of NHS and private patients, face-to-face, by telephone or by Skype; providing dietary advice to patients before and after bariatric surgery; motivating and supporting patients with behaviour change for long-term success; working within a multidisciplinary team; carrying out gastric band fills (training provided); participating in 24/7 on-call helpline cover; admin, data collection, audit and analysis as required. Application deadline: 17th Nov 2015 Interview date: 27th Nov 2015 Start date: 4th Jan 2016. Please email your CV to sally@phoenix-health.co.uk For an informal discussion, please contact Sally on 07585 047 188. www.phoenix-health.co.uk

Paediatric Specialist Dietitian, Band 7 London We are currently looking for an experienced Paediatric Dietitian to cover a full-time (37.5 hours per week) two-month post in London. Extensive experience of working with children within Diabetes and Insulin Pumps. This is a community post covering schools, patients’ homes and hospital clinics. Please call Elite Dietitians on 01277 849649, or email: hayley@eliterec.com.

Band 6 Acute Dietitian - ESSEX Band 6 Dietitian required for an acute post to start as soon as possible. This is a full-time post covering adult wards. Please call 01277 849649, or email hayley@eliterec.com. Visit www.elitedietitians.com

Band 5/6 Community Dietitian - North West England North West England Band 5/6 Community Dietitian is required to cover a nutrition support role covering Clinics and Home visits. Applicant must have own transport. Starting as soon as possible, full time until the end of December. Please call 01277 849649, or email hayley@eliterec.com. www. elitedietitians.com

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Band 6 Acute Dietitian - Berkshire Band 6 Dietitian required to cover general acute wards for approximately eight weeks, starting as soon as possible. This is a full-time post, 37.5 hours per week. Please call 01277 849649, or email hayley@eliterec.com. www.elitedietitians.com Band 6 Paediatic Acute and Community Dietitian - KENT Starting middle of November, this is a two-day post covering both community and acute work. A car is required for this post in order to carry out the community aspect. Please call 01277 849649, or email hayley@ eliterec.com. www.elitedietitians.com

CAREER

events and courses University of Nottingham - School of Biosciences Modules for Dietitians and other Healthcare Professionals • Diabetes 1 & 2 - 14th & 15th Jan 2016 • Understanding Behaviour Change 9th & 10th Feb & 22nd March 2016 For further details please email: lisa.fox@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’. Healthy eating: What the science says 11th Nov Conway Hall, 25 Red Lion Square, London WC1R 4RL www.eventbrite.co.uk/e/autumn-2015-lecture-seriestickets-18117237144

Diabetes Professional Care 2015 11th-12th Nov London’s Barbican Exhibition Centre www.diabetesprofessionalcare.com Introduction to Childhood Obesity BDA Trainer 17th Nov London Road Community Hospital, Derby Full details at www.ncore.org.uk Food Matters Live 17th Nov ExCeL London www.foodmatterslive.com Partnerships in Clinical Trials 17th-19th Nov Hamburg www.informa-ls.com/event/PCT2015

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

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 November 2015 - Issue 109

A Day in the Life of…

. . . a Dietetic Support Worker: Nephrology I am one of four Dietetic Support Workers (DSWs) at the Bristol Royal Hospital for Children. I work with the Renal team, others work with patients with Cystic Fibrosis, Metabolic diseases, Cancer, Gastroenterology and Burns.

Rachel Smith Dietetic Support Worker, Bristol Children’s Hospital

Rachel is a Renal Dietetic Support Worker at the Bristol Children’s Hospital. Her goal is to go back to university to study to become a dietitian.

We run regular audits throughout the hospital to ensure that our service is meeting the needs of the Care Quality Commission Regulation 14, including nutritional screening. We support catering developments, set up new supplement orders from the hospital pharmacy for our inpatients and monitor the stock of supplements on our respective wards. Many of our patients are fed via nasogastric tubes or gastrostomies; despite this, we can ensure optimal nutrition at home, school and nursery, and even out and about. We also help the dietitians by liaising with our Home Enteral Feeding team to ensure that correct feed deliveries take place. To extend our knowledge and skills, we also support our Special Feed Unit twice a month. Here we make up specialised feeds in a safe environment, which allows us to become familiar with concentrations and dilutions, and we quickly learn to associate certain feeds with specific conditions. Our feeds are mostly paediatric specific and can differ in suitability of age-range. The knowledge I have picked up from my time in the Special Feed Unit has been very useful. My role as a Paediatric Dietetic DSW for the Renal service, is currently funded by the British Kidney Patient’s Association. My remit is to support the two qualified dietitians who specialise in Renal Disease in this specialist tertiary hospital, which supports all the local hospitals in the South West of England. Due to the nature of Chronic Kidney Disease, I get to see many patients on a regular basis and witness all their ‘ups

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and downs’ throughout progression and treatment. Getting to know the children, parents and carers well allows me to gain a better insight when taking diet histories and to offer realistic low salt and healthy eating advice. Despite living with these conditions, these children are some of the most determined and cheerful little critters I have ever come across and this exudes strength to their parents. In the renal service, we monitor patients’ biochemistry very closely; altering levels might result in feed plans and diets being adjusted accordingly. Haemodialysis can alter these readings, so bloods must be checked both before and after. Haemodialysis usually lasts around three hours and patients can be in two to four times a week! Micronutrients are also checked and vitamin/mineral supplements might be added. I spend time each week pulling patient notes and filling in recent biochemistry, anthropometric information in preparation for meetings and clinics. As kidney disease progresses, a patient’s ability to maintain appropriate biochemical levels deteriorates and so their dietary needs change. These diets can be very complex and the dietitians advise all complex patients. However, I can offer low salt advice when asked by the dietitian and healthy eating advice to post-transplanted children. As renal diets can be extremely restrictive, after a transplant, getting children to eat a healthy and balanced diet can be extremely challenging; some children may need to redevelop a positive relationship with food or learn eating skills.

a day in the life of . . .

Children with this condition are at risk of growth problems, so this means that we need to closely monitor growth. Part of my role is to regularly plot height, weight (and head circumference for babies) for the dietitians. Through taking diet histories I am able to help patients express their likes and dislikes and I have worked with the dietitians to obtain school menus in order to check that the children are getting as much choice as possible. Most sick children we see need high energy diets alongside restrictions. We often experience difficulties when getting children to try supplements and I enjoy the challenge of creating different options, such as ‘renal shakes’ to get our patients to try them. We have a resident Play Therapist who is fantastic at supporting us too. My additional tasks can range hugely on a day-to-day basis. Since my start in January this year, I have created an à la carte renal-specific menu and snacks list for our babies, toddlers and children. I have aided in the organisation and running of a national renal recipe competition, an initiative set out via the Paediatric Renal Interest Nutrition Group to create a recipe book which will hopefully be available to paediatric renal patients by next year. I have also created a Guide to the Nutrition and Dietetic Service leaflet for Ward staff, outlining what we offer as a service,

how to contact us and find our guidelines and information and how to obtain specialised feeds (amongst other things). I was lucky enough to lead on organising and running a ‘Salt Awareness Week’ stand alongside the National ‘Salt Awareness Week’ which was aimed at raising awareness of hidden and added salt within foods. As a result of the success of this, I now work with others to create a regular health promotion corner in the outpatient waiting area and have since gone on to organise a similar event on ‘sugar and dental health’. The paediatric DSWs have an abundance of ideas for future projects and I am excited to get stuck in. Alongside my renal specific role, I also maintain the department website and create and distribute our monthly newsletter, Nutrition Mini Bites, which is sent out to staff to update them on all things nutrition and dietetic! My role as a DSW is a healthy balance of patient contact, sourcing information, creating resources and helping with administration. Our small renal dietetic team supports each other, as well as the whole multidisciplinary team, to optimise the health of our patients on a day-today basis. Our team goal is helping our children achieve healthy lives and I am pleased to be a part of this. NHDmag.com November 2015 - Issue 109

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EXTRA

Issue 109 November 2015

IBS and THE LOW FODMAP DIET by Majella O'Keeffe HOSPITAL FOOD STANDARDS: WHAT DOES THIS MEAN FOR DIETITIANS by Diane Spalding and Anne Donelan

EXTRA NHD ARTICLES FOR SUBSCRIBERS ONLY

NHD extra - ibs & fodmaps

Group Education and the Low FODMAP Diet These days, it is not uncommon to see headlines outlining the financial doom and gloom faced by the National Healthcare Service (NHS). Departments, including Nutrition and Dietetics, have suffered reduced budgets, staff cuts and hiring freezes, yet are expected to maintain optimal patient care and service delivery. Majella O’Keeffe Registered Dietitian

Majella is a Registered Dietitian and PostDoctoral Research Associate currently working at King’s College London in the area of diet and gastrointestinal health.

Patient demand for services remains high and patients with irritable bowel syndrome (IBS) represent a significant proportion of patients seen by Nutrition and Dietetic services. Waiting lists for dietitian-led management of IBS are often excessive and novel methods for delivering dietetic care while optimising cost effectiveness are necessary. This article is based on a recent service evaluation investigating the clinical and cost effectiveness of group versus oneto-one education for the low FODMAP diet in IBS. IBS affects approximately 10-15% of the UK population and women are twice as likely as men to suffer from the condition.1 The origin of IBS is unknown, but biological, psychological and social factors are implicated in the development of the condition. IBS is characterised by abdominal pain, bloating, bowel urgency, diarrhoea and or constipation. IBS pathogenesis is diverse and includes alterations in gastrointestinal motility and sensitivity2, increased colonic fermentation3, abnormal gas transit4, altered gut-brain communication5 and changes in the composition of the gastrointestinal microbiota.6-10 Psychological issues, such as stress and anxiety11,12 also play a role. IBS is also associated with significant societal13 and health-related economic costs14,15 as well as impaired quality of life.16 Management of IBS

Management therapies include pharmacological, cognitive and dietary man-

agement, e.g. a diet low in fermentable oligo-, di-, mono-saccharides and polyols (FODMAPs). FODMAPs are poorly absorbed in the human gastrointestinal tract and increase gas production via colonic bacterial fermentation. In susceptible individuals, they give rise to IBS-like symptoms (bloating, flatulence, diarrhoea). The low FODMAP diet involves four to eight weeks of FODMAP restriction to improve symptoms. FODMAPs are then systematically reintroduced to tolerance, allowing identification of individual-specific FODMAP triggers which induce symptoms. FODMAP reintroduction is important to increase the diversity of the diet while identifying known trigger foods. The scientific evidence behind the diet is gaining significant momentum17-20, with increasing randomised controlled trials demonstrating notable efficacy of the diet in approximately 70% of all patients with IBS.21-24 The National Institute for Health and Care Excellence supports the use of the low FODMAP diet in IBS management.25 Comprehensive patient education on the diet is the cornerstone of its success. Equipping patients with the knowledge and confidence to undertake the diet correctly and self-manage their condition is imperative and research supports dieteticled education. However, this is both timeconsuming and labour intensive. The low FODMAP diet is usually delivered under a traditional service delivery pathway, a one-to-one consultation between dietitian and patient. However, data from other NHDmag.com November 2015 - Issue 109

NHD Extra - ibs & fodmaps conditions suggests that group therapy is an effective treatment delivery method for long-term chronic diseases such as diabetes26, asthma27 and obesity.28 Benefits associated with group therapy, including improved clinical effectiveness29-31, increased patient empowerment30,32, peer support and enhanced cost effectiveness.33 Group therapy has been shown to be effective in overall management of IBS31, but information specific to the dietary management of IBS was lacking until a recent service evaluation investigated the clinical and cost effectiveness of group therapy for the low FODMAP diet in the management of IBS.20 The development of the novel group education model reported in the service evaluation, was influenced by the growing demand for low FODMAP education and in response to increased waiting lists. In brief, the group pathway included an initial telephone clinic during which referred patients were pre-screened for inclusion in group education. Patients with atypical symptoms, complex clinical history and limited English comprehension were offered a one-to-one appointment. There will always be patients for whom group education is not appropriate. Group education can, therefore, never supersede one-to-one delivery, but rather, may be offered as ‘the norm’ with one-to-one sessions only provided to those who are not suited for group care. During the initial appointment, participants of both the group and one-to-one group were provided detailed information on the low FODMAP diet. A second follow-up appointment (group or one-to-one) for FODMAP-reintroduction advice was arranged for at least six weeks later. Symptoms were recorded at initial and follow-up appointment and included validated tools used to assess overall and individual symptoms. Group acceptability was also assessed. The costs of the novel group pathway were compared to the costs associated with a theoretical one-to-one pathway. The main findings are outlined below: 1. Clinical effectiveness • The low FODMAP diet was equally effective in improving overall IBS symptoms in both the group and the one-to-one education arms (54% vs 61%, p=0.271 respectively). • There was a significant decrease in individual symptom severity in both groups. 52

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• Stool consistency and frequency improved in both groups, with no differences found between groups. • There was no difference between the clinical effectiveness of the group versus oneto-one education. 2. Acceptability • 64% of patients in group pathway either preferred or expressed no preference toward group or one-to-one education. Approximately one third of patients would have preferred one-to-one education. • 81% of patients reported that group education provided sufficient information to enable them to manage their symptoms using the low FODMAP diet. • Patients in the group clinic were happy to ask questions in this environment (85%). • Group logistics were acceptable: 97% of patients were content with duration of education; 94% were satisfied with the content of the group session; 87% found the written information easy to follow and 97% of patients agreed that education and patient involvement in the group were ‘just right’. • Compliance among group participants was high; 81% of patients reported complying with the diet 75% of the time. 3. Cost analysis • Total cost for the group pathway was £31,731.36 (364 patients). The group pathway discussed in this study consists of a telephone clinic, group clinics as well as the ability to see patients in a one-to-one clinic. It is important to recognise that any group pathway must include the ability to see patients individually as clinical need or complex patients may require dietetic review in a one-to-one capacity. Breaking down the costs of the group pathway, of the total number of patients who were counselled under the group pathway, 263 patients received group education whereas 101 patients received one-to-one education. The respective costs for both the group and one-to-one clinics, which exist with the group pathway, were £17,671 and £14,059 respectively.

The costs associated with a group pathway were significantly less compared to a theoretical one-toone pathway

• The total costs for the hypothetical one-toone pathway were £44,149 for 364 patients. Given the absence of a control arm in this study, hypothetical costs were determined for a one-to-one pathway (see Whigham et al, for full cost analysis). 20 • The difference in cost between the group pathway and the hypothetical one-to-one pathway for 364 patients was £12,418. • The cost per patient of the group and oneto-one pathway was £67.19 versus £139.20 respectively. In summary

This study demonstrates that a group pathway is a clinically effective model of dietetic service delivery for education on the low FODMAP diet in the management of IBS. There was no difference in the proportion of patients reporting symptom improvement between groups. Individual symptom response improved in both groups, although a greater proportion of patients reported reduced abdominal pain and lethargy following group education, suggesting that interplay between peer support and group dynamics may enhance symptom response. However, more research is needed to substantiate these findings. Additionally, group education was acceptable to the majority of patients. The costs associated with a group pathway were significantly less compared to a theoretical one-to-one pathway, with a potential saving of more that £12,000. Extrapolation of these findings suggests that for every 1000 patients reviewed in under a group pathway, rather than one-to-one pathway, cost savings may be in excess of £34,000. Given the financial limitations facing Nutrition and Dietetics services

in the NHS, and the importance of efficiency savings, the viability of group education needs serious consideration. However, the findings of this study need to be interpreted with due care. The study was a prospective observational service evaluation which lacks the rigour of a randomised controlled trial. The absence of a defined control group limited the cost analysis which was based on a theoretical model. Additionally, allocation of participants was not random and no power calculation was undertaken. Therefore, there is a need for future prospective, adequately powered randomized controlled trials to further evaluate the clinical and cost effectiveness of group education pathways for the dietary management of IBS. Nevertheless, this is the first study to investigate a novel group pathway and the findings suggest that a group pathway may be an effective dietetic service delivery model that maintains clinical and patient-centred outcomes whilst potentially reducing healthcarerelated expenditure and optimising dietetic labour and resources. Research in this area is ongoing at Guy’s and St Thomas NHS Foundation Trust and King’s College London. Citation of the full paper discussed above: Whigham L, Joyce T, Harper G, Irving PM, Staudacher HM, Whelan K, Lomer MCE (2015). Clinical effectiveness and economic costs of group versus one-to-one education for short-chain fermentable carbohydrate restriction (low FODMAP diet) in the management of irritable bowel syndrome. J Hum Nutr Diet. Doi: 10.1111/jhn.12318. for article references please email info@networkhealthgroup.co.uk. NHDmag.com November 2015 - Issue 109

NHD extra - HOSPITAL FOOD STANDARDS

HOSPITAL FOOD STANDARDS: WHAT DOES THIS MEAN FOR DIETITIANS? The Hospital Food Standards Panel’s report on standards for food and drink in NHS hospitals was published by the Department of Health (England) in August 2014. Diane Spalding and Anne Donelan discuss the implications and opportunities that this national policy document gives to improving nutritional care in hospitals. Diane Spalding Facilities Dietetic Advisor, Leeds Teaching Hospitals NHS Trust

Anne Donelan Consultant Dietitian with Tillery Valley Foods

Along with her current role in the NHS, Diane is Admissions Tutor, PG Dietetics at Leeds Beckett University and works as a Freelance Dietitian. She has always worked closely with patient catering services.

Although retired in 2012, Anne is a Committee Member of the BDA Food Services Specialist Group, BDA Ambassador and Life Member of Hospital Caterers Association. She is a BDA rep on the multi-agency ‘Last 9 Yards’ Group.

Both Anne and Diane have extensive experience working as dietitians involved with hospital food and are passionate about the important role that dietitians have in delivering a high quality food and beverage service. Anne was a member of the Hospital Food Standards Panel and Diane has been working directly as part of the patient catering/facilities team within an NHS Trust. In this article, Diane asks Anne some pertinent questions about the Hospital Food Standards Panel and also gives her own views on implementation. What was the Hospital Food Standards Panel and how did you get involved? AD: The Panel was an independent group convened by the Department of Health (DH) on behalf of government by the Secretary of State for Health. The Panel worked with leadership from Dr Dan Poulter, Parliamentary Under Secretary for Health, and with excellent Chairmanship under Dame Dianne Jeffrey. Dianne has a breadth of relevant experience and her particular insight as Chairman of Age UK was fundamental to the good working, deliberations and outcomes of the Panel. I was invited to join the Panel as Chair of the BDA Food Counts Group. I had ‘met’ DH lead Dr Liz Jones via a couple of conference calls she placed with me and DH colleagues, as she was keen to understand the impact of The Nutrition and Hydration Digest1 in supporting the needs of nutritionally

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vulnerable patients. Their belief was that, within a whole hospital population, healthier eating was the key issue, as the percentage of people (including visitors and staff) who require a healthier ‘eatwell plate’ approach was higher compared to those who are nutritionally vulnerable on admission to hospital (approx c30%2). This key issue was ironed out during the Panel and ERG deliberations, but is still a thorny one for trusts when preparing their Food and Drink Strategy, and I will return to this later. DS: I think it was really important to have a dietitian with your level of experience involved in developing national policy on the Hospital Food Standards Panel. Working at this level gives opportunities for promoting good nutritional care in hospital and other care settings and so is a vital part of the role of a dietitian. I was involved in the Better Hospital Food Programme3 and the interest at the time in the evidence base for nutritional standards for hospital food and meeting the needs of the diverse patient groups led to the formation of the BDA Food Counts Group. I remember that, prior to this time, the previous national policy documents were not always appropriate for the breadth and depth of needs of the current patient population in hospitals and, so, nutritional standards were not updated and defined until the BDA Food Counts Group published Delivering Nutritional Care through Food and Beverage Services4 in 2006. Prior to this, the British Dietetic Association had published The Dietetic

NHD extra - HOSPITAL FOOD STANDARDS Interface with Food Service; A Professional Consensus Statement5 in 2002, which was aimed at drawing the attention of dietitians to the pivotal role that they play in ensuring the provision of appropriate and nutritious food in a patient focused food service, following the previous publication as part of the Health of the Nation public health strategy.6 Who else was involved? AD: The ’roll call’ is transparent and listed within the report. In summary, the Panel was an eclectic mix of representatives from relevant government, professional, healthcare, patient, campaigning and charitable organisations, along with some key informants in the field of hospital food and beverage services and included a lay member. It was clear that, in addition to the overall expertise and experience provided by Panel members, a practical and academic focus was needed in three key areas to substantiate the Panel’s requirements and recommendations. Expert Reference Groups (ERG) were convened to explore these identified issues indepth: patient nutrition and hydration; healthier eating across hospitals and sustainable food and catering services. Guided by DH, Panel members and invited experts within these fields met on a ‘task and finish’ basis to agree the evidence base and implications within these three domains that underpin the Panel’s Report. DS: It is good to hear that a wide selection of people from different backgrounds and agendas were involved, including patients and their representative organisations, some of which have been very proactive in highlighting and helping to address some of the areas of concern about nutritional care in hospitals. Food, nutrition and hydration care requires a multidisciplinary approach, with the patient being a key player in this. Within my work in patient catering in the NHS, we have tried to ensure that patient feedback drives the direction of changes that we make and we have involved patient representatives so that they are influential in agreeing whether items are suitable to be added to the menus or not, as part of quality taste testing panels. We have also used this group to inform changes to the menu format and style, including the development of a bistro-style lunch, fish and chips on Friday, themed Indian/Chinese takeaway on Saturday evening and Sunday roasts.

What impact do you think this will have on NHS Trusts? AD: As the requirements of the Report are integral to the 2015/6 NHS Contract agreed with commissioners, I hope the impact will be huge! This is the first time that such non-clinical activity is called upon to account for itself. But I also think that it may be too much too soon and a transitional learning curve must be anticipated, especially as some of the practical detail of the Panel’s expectations was not published until six months after the initial report.7 Several enabling complementary work strands are underway. DH have published on their website a Food and Drink Strategy Toolkit8 and a Prezi designed to engage and inform key trust personnel on how to go about working and delivering their interdisciplinary policy. In essence, this is a Trust’s annual improvement programme based on their own gap-analysis specific to the challenges of their own sites, their own food and beverage services and their unique patient/ staff/visitor populations. NHS England is committed to enabling commissioners to understand what is required within the annual contract, which is legally binding. The Hospital Caterers Association (HCA), through its ‘Last 9 Yards’ multi-agency group (a term which arose from the final Panel meeting), has ‘bitten the bullet’ on behalf of its members and published their view of how a Food and Drink Strategy could be developed (accessible on the members section of the HCA website www.hospitalcaterers.org). The model envisaged is Trust Board-led (ideally by the Director of Nursing or equivalent), entailing regular reports to the Board and a formal annual report on the achievements in meeting the aspirations of their agreed multiagency Food and Drink Policy and plans for the coming year. Placing this level of importance and scrutiny is fundamental to ensure that commissioners are satisfied with the firm intent in delivering targets that the trust has set in the annual cycle of their Trust Food and Drink Strategy. BDA Food Services Dietitians Specialist Group has developed a checklist for Trusts to use to check their compliance with the Digest, which DH is distributing via its website. NHDmag.com November 2015 - Issue 109

NHD extra - HOSPITAL FOOD STANDARDS DS: I have been involved in developing a Food and Drink Strategy within Leeds Teaching Hospitals NHS Trust. I agree that this needs to be an interdisciplinary approach and have an acknowledged status at a high level within an organisation. The Strategy also needs to involve other key players within nutritional care across the healthcare community in primary care and local authorities. We have found the sharing of ideas to be extremely beneficial. The Food and Drink Strategy can be developed using the work plans of a Trust’s Nutrition and Hydration Care Steering Group (NICE Guidance, Nutritional Support for Adults9) and so much of the gap analysis and action planning may have already been documented, particularly for patient nutritional care. However, I do think that as dietitians we need to ensure that we take an evidenced and scientific approach to approving patient menus within our organisations. To do this, it is essential to use The Nutrition and Hydration Digest as a reference for the nutritional targets to be met. In my work as a dietetic advisor to patient catering, I have found the Day Parts Approach referenced in The Nutrition and Hydration Digest to be invaluable and have been able to use this to define the nutritional targets for individual items on each section of the menu in order to achieve the targets in the Day Parts for both the nutritionally well and the nutritionally vulnerable patient. All items need to meet these minimum targets before being considered for inclusion on the menu. It is also essential to do a regular Nutritional Capacity Report in order to demonstrate the compliance required. I am aware that many nutrition and dietetic departments are not adequately resourced to undertake this work; however, I do feel that the requirement to produce a Food and Drink Strategy and also the requirement to be compliant with The Nutrition and Hydration Digest gives a real opportunity for dietitians to evidence the need for this expertise and specialist resource, as we have the skills and expertise to give this assurance. The Checklist for compliance with The Nutrition and Hydration Digest will, therefore, be a useful tool in identifying gaps and should be included in Trust Food and Drink Strategies. What was it like being a dietitian on the panel and what were the challenges? AD: The first meeting in early December 2013 was probably not my best! There was a landslip 56

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down-line from my mid-Kent station and, despite all my careful planning, I was late to the inaugural meeting held in the hallowed quarters of Church House, in Dean’s Yard, Westminster. However, Dianne was welcoming and made me feel at ease, but I was pretty concerned to try and identify those I didn’t know, i.e. who was who and from where. I recall that although I nervously contributing on several points, I felt comfortable that Panel members were supportive of my observations. As the only food services dietitian, I was one of the few wearing a ‘scientific hat’ and I could sometimes apply this to my advantage within Panel and my ERG (the Defra-led Sustainability, Animal Welfare and Food Waste). Despite some qualms, I had decided to give this group my best shot and leave the more comfortable areas of patient and staff /visitor feeding to co-opted colleagues. I am glad I did; I learnt a lot and was fascinated by the passionate input of some others whose views I did not share, but which gave me food for thought. What opportunities do you think this gives to the dietetic profession in the NHS? AD: As dietitians we have a raft of interpersonal and presentation skills that complement our professional expertise. We have an evidencebased clinical view of the importance and place of food as treatment. We understand ‘food and figures’, i.e. balancing the nutritional content of different foods within a multi-choice menu. We can assess quickly menu capacity and calculate the detail of nutritional delivery if required. In addition, we have a thorough knowledge of our trust sites, know many of our peers and personnel from board to ward and have a fair overview of the challenges from food production, transport and kitchen level to ward service. In our day job, we speak constantly with patients, their relatives and carers about food likes and dislikes, and often hear their unsolicited views about hospital food! So we have an overall appreciation of what people like to eat, coupled with the challenges in the logistics of providing appropriate 365-day/24-hour quality food and beverage services to patients, hospital staff and visitors - within a tight budget and frequently with stretched staff resources.

NHD extra - HOSPITAL FOOD STANDARDS Table 1 THE 5 STANDARDS As required by the Hospital Food Panel Report Three for patient catering • 10 key characteristics of good nutritional care, Nutrition Alliance • The Nutrition and Hydration Digest, The British Dietetic Association • Malnutrition Universal Screening Tool (or equivalent i.e. a validated tool) (BAPEN) For staff and visitor catering (and applied as appropriate to patient catering; the specific nutritional needs of individual patients should always supersede the application of blanket principles) • Healthier and More Sustainable catering - Nutrition Principles (Public Health England) For all catering • Government Buying Standards for Food and Catering Services, HMG standards developed by the Department of Environment, Food and Rural Affairs

As a member of a multidisciplinary group - such as one that would develop a trust Food and Drink Strategy - dietitians have good team working skills and have the knowledge and language to identify and interpret the concerns of others who may not have the same understanding of the ‘bigger picture’ when it comes to catering for such a diverse population. They can work with catering and nursing colleagues in a way that fosters mutual trust and respect, agreeing and collaborating on shared goals so that the whole is more than the sum of the parts. They could also nudge their catering colleagues to provide cake - always a welcome enabler at meetings! It is so easy to talk about food when you are fit, well-nourished, not anxious and in decent health; we can help our team ponder on that and how patients and their relatives may perceive the same food and beverage services that we are all considering. DS: Many of the comments you have made are exactly the reasons why dietitians need to be an integral part of the patient catering service. At the start of our professional career path, dietitians were very involved in patient catering, often to the extent of being based in or near the catering department. Times have changed and, as a profession, we have generally moved away from the close involvement with patient catering services and yet this involvement now seems to be becoming more important as it gives us an opportunity to impact on every inpatient’s nutritional care - not just the small percentage who require specific dietetic intervention.

One of my concerns is the diversity of nutritional needs of patients in hospital - how has the Food Standards Panel addressed this? AD: One of our major tasks was to wade through over 50 publications relevant to public sector/ hospital food services and focus down to a few robust ‘required’ documents. Through scrutiny and agreement by Panel and ERG members, this was reduced down to the five key documents (see table 1) that are the evidence base to underpin NHS food and beverage services. Whilst references to all five are essential, there is scope for each trust to tailor their strategy to meet the nutritional and food and drink needs of their unique patient and staff population. The thorny issue of how to meet patients’ diverse nutritional, therapeutic, texture and cultural food and beverage needs is far more demanding than the straightforward ‘healthier eating’ for staff and visitor catering. The Panel and ERGs addressing this challenging inconsistency through the Healthier Eating Across Hospitals and Patient Nutrition and Hydration teams, were very clear on this point. Tackling this diversity of practice is key when it comes to a Trust cross-professional team agreeing their approach and making sure that the span of needs from nutritionally well to nutritionally vulnerable patients is covered. DS: I believe that the Hospital Food Standards Report covers these diverse needs very well, describing ‘healthy eating’ for the nutritionally well patient and ‘eating for health’ for the nutritionally vulnerable. The Nutrition and Hydration Digest also covers the diverse range NHDmag.com November 2015 - Issue 109

NHD extra - HOSPITAL FOOD STANDARDS Figure 1

of nutritional targets for these two extremes of patient nutritional situations and an organisation needs a nutritional capacity report to be able to demonstrate that all patient needs are covered. However, we should be aware that, although across the whole hospital population (patients, visitors, staff), the nutritionally vulnerable patients are the minority (c30%), these are the patients who require greater consideration and attention in terms of their food and drink requirements and not getting this right could be more costly both for the patient, their carers, their relatives and for the organisation (due to longer hospital stays, readmission rates, increased mortality). Although they are a smaller percentage, they will, therefore, justify more resource to address their needs. However, the higher energy choices suitable for the nutritionally vulnerable patient should not be just higher in calories - the types of food items chosen for the menu should be appropriate for a healthcare environment, giving an impression which is associated with wholesome and healthy food. As well as the nutritionally well and the nutritionally vulnerable patients, there will be others who have specific dietary or clinical needs and this also needs to be addressed (e.g. patients requiring texture modification for dysphagia, renal conditions, neutropenic diets). From my experience we need to work closely with the clinical teams to ensure that specific patient needs are met and a dietitian working in patient catering is an ideal person to establish and ensure this joint working takes place. Dietary coding is also important and in the past 58

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has often been developed for staff guidance rather than for the patient. Dietary coding should be focused on aiding the patient to make appropriate choices for their own specific needs. It should be minimal, non-technical and not confusing. I remember James Martin asking the question in his TV programme, “What does Reducing mean?” We should not assume that the patient will understand the terminology that we as healthcare professionals use. Hospital menus are hard enough to understand when you are unwell, apprehensive and in a strange environment without having professional jargon and confusing codes. How should NHS Trusts practically implement the recommendations in the Food Standards Panel report? AD: One of the exercises undertaken by the DH when finalising the Panel’s report was to undertake a cost benefit analysis of the recommendations. Nutrition and Hydration Digest Team Leader, Maxine Cartz, and I were invited to meet with a DH economist to see how The Digest ‘shaped up’. This was initially an alarming idea, but one that was most rewarding when we saw how useful The Digest is for underpinning developments in nutrition and dietetic services. In particular, promoting multidisciplinary menu planning, dedicated catering liaison time, weekly malnutrition screening, snack provision, improving patient safety and waste policy and audit. So, these are the areas that are likely to be monitored in the future and to which dietitians

NHD extra - HOSPITAL FOOD STANDARDS can have positive influence in a team role. Note that they are not necessarily leading in these areas, but have firm intention from the Digest to be involved in areas that they may currently not be, e.g. waste audits (uneaten food has no nutritional benefit); patient safety discussions (case for appropriate textures, therapeutic diets); business case for a level of waste to energy dedicated dietetic/catering liaison. Within The Digest, there are tools to enable qualitative and quantitative assessment of patients’ nutritional needs through a day parts approach and for assuring nutritional adequacy through simple or detailed menu capacity checks. As mentioned, both the Financial Sustainability Strategy Group (FSSG) and HCA Last 9 Yards groups have developed guidance or checklists for their members to monitor their progress. Patient-Led Assessments of the Care Environment (PLACE) and in-house satisfaction questionnaires provide constant rigour. During these early days, it is likely that these will be quite enough for dietitians and their cross-professional team colleagues to contend with, to develop and monitor their fledgling strategies without recourse to more demanding audits. This is a period of acquiring a new way of thinking and working together to improve food and beverage services trust wide, and will doubtless benefit for some bedding down time before taking flight to tackle more demanding audit programmes. DS: From my experience, taking time to develop a Trust Food and Drink Strategy is a good place to start and working through the Toolkit to support the development of a Food and Drink Strategy8 (see figure 1) gives a useful process for this. The Strategy can be written in the three sections suggested: 1. Patient nutrition and hydration. 2. Healthier eating for the hospital community, especially staff. 3. Sustainable procurement of food and catering services. We have found that much of the patient nutrition and hydration section has already been covered by the work of the Trust’s Nutrition & Hydration Steering Committee, with a gap analysis and action plans already identified, so this has mainly involved referencing and signposting to this work. It is important to recognise

that this is not just about the catering service, but all the people involved, policies, guidelines and systems in place to provide good nutritional care (service skills, attitudes, encouragement given to patients, protected mealtimes, nutritional screening, support and help given at mealtimes, including mealtime volunteers, discharge processes and communication on discharge). Working through the 10 key characteristics of good nutritional care and The Nutrition and Hydration Digest checklist is a good way of working through the Patient Nutrition and Hydration section as well as using feedback from PLACE assessments (NHS Choices website).10 This will also require some dedicated dietetic time linked to the Patient Catering Service. The third section on ‘Sustainable procurement of food and catering services’ can also use the Government Buying Standards as a checklist to undertake a gap analysis and action plan. However, it is more difficult to cover the second section ‘Healthier eating for the hospital community, especially staff’, because a standard format has not yet been developed for this, although this would be beneficial to ensure a standardised approach across organisations. Some of the areas in the Government Buying Standards (GBS) do not seem to be appropriate for the ‘nutritionally vulnerable’ patient in hospital - how did the Food Standards Panel address this? AD: As already discussed, the Hospital Food Standards Report clearly differentiated between ‘healthier eating’ for staff, visitors and patients and catering for the needs of nutritionally vulnerable patients and the ERGs were very clear about these differences. The Hospital Patient Nutrition and Hydration ERG created an ‘island’ for catering for hospital patients by requiring three patientfocused standards (see table 1) to be met (10 key characteristics, compliance with The Digest and use of a validated nutritional screening tool). So, as long as patient food and beverage services can demonstrate that the three standards are met with compliance with GBS where appropriate, the key nutritional driver that underpins patient catering is The Digest, which does, of course, tackle both ends of the spectrum. The Sustainability, Animal Welfare and Food Waste ERG took a similar view and were keen on the ‘balanced score card’ approach that Defra was then developing for public sector catering. Helpfully NHDmag.com November 2015 - Issue 109

NHD extra - HOSPITAL FOOD STANDARDS The Digest starred here as well, as in Chapter 4 it reminds dietitians to be mindful to support and develop patient food services (for example, range and choice of menus and snacks) in a sustainable way that provides ‘good value for money’. So, overall the ERGs allowed a degree of weighting of pertinent factors so that food, beverage and snack services for in-patients that include a good choice of familiar and comforting foods with plenty of energy from fats and carbohydrates is quite acceptable where this is clearly evidenced and also underpinned by the Panel’s required documents. DS: Many of the Government Buying Standards which relate to nutrition are also appropriate for and/or can be applied to nutritionally vulnerable patients and can easily be incorporated into the higher energy choices on the menu and, therefore, do not conflict with their nutritional care. This includes the use of fresh seasonal produce, fruit-based higher energy desserts, vegetables, higher fibre cereals and provision of fish, including oily fish on the menu. It is more difficult to achieve the same salt restriction in higher energy choices as it is for the ‘healthier options’; however, it is possible to limit this and I have ensured that the higher energy choices of the menus at Leeds are within a maximum salt limit. Restrictions in fat, saturated fat and sugar may be more difficult and inappropriate for the nutritionally vulnerable patients, but there can be adequate justification for this. For many patients, including those who we need to encourage to eat, it is more important that the menu contains some locally produced, fresh and wholesome food which patients can recognise and associate with quality. Using local dishes and familiar dish names can help to encourage the more nutritionally vulnerable patients to eat and take an interest in their meals. At Leeds this has worked well with locally produced and well recognised dairy ice cream and freshly baked, locally produced cakes which are served with afternoon tea on the older adult wards, providing a valuable higher energy snack. What do you think dietitians should do and where can they find out more? AD: Don’t try to ‘go for gold,’ i.e. 100% compliance, straight away. The strategy is a plan for regular improvement based on your own Trust’s identified areas of weakness. Fix one and another will likely come along…and that’s for next year’s strategy. The same applies to 60

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dietetic developments - not looking for fulltime dedicated catering dietitians, just some funded and ring-fenced hours. Build on this as the benefits become apparent to the wider trust team. Seek to apply GBS where comfortable and plan to extend on that next year where there is sound opportunity. Choose areas where there are some ‘quick wins’ for healthier and sustainable catering in beverage, accompaniments/ snack services, e.g. stand-alone dairy items like cheese portions, yoghurt and milk, rather than wading straight into the more challenging areas. When it comes to complete dishes, focus on the overall nutritional delivery and in maintaining flavour and appeal, rather than every ingredient being a good fit with GBS. As the Report states, ‘…it is not enough for hospitals to deliver food that meets the letter of the standards if its flavour and presentation are poor…it must taste good as well’. Amending tried and tested costed standard recipes is a lengthy task which can be a transitional aspect of your food strategy. The panel was clear that food should crucially be a source of pleasure and enjoyment within the patient experience. As dietitians who are trained to be objective and fact-based, we can take an impartial perspective of the whole process. To allay the fears of Hospital Food Standards critics, our eye for detail means that we fully appreciate the demands inherent in meeting the complex and detailed requirements of the five required standards and the binding power of the NHS Contract in making that mandatory. DS: As a dietitian with experience of working within a patient catering team in an NHS organisation, I would suggest that in order to find out more, dietitians need to be aware of: • BDA Food Services Specialist Group - the work programme and the membership as a valuable network • HCA website and get involved - join them and go to Branch Meetings! • DH website - particularly related to hospital food • NHS choices website ratings for hospital food in each NHS organisation • Work within their Trust (PLACE assessments, Food & Drink Strategy, etc) for article references please email info@networkhealthgroup.co.uk.

the final helping Thoughts from almost abroad with Neil Donnelly . . .

Neil Donnelly

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

Some years ago now, my wife and I left home with our suitcases to embark on a well-earned break in the sun. We were flying from our local airport in Blackpool, only a matter of 10 minutes away from our home, to Alicante in Spain. Blackpool airport, now sadly closed for such flights, only numbered around a dozen departures each day, so checking in was relatively quick and trouble free. On this occasion, we were dropped off and headed towards the check-in desk. After a few minutes or so, it was our turn to hand over our passports and tickets to the young lady behind the desk and wait for instructions. I duly loaded my case onto the scales and waited for it to bounce along the conveyor belt and disappear and then load our second case. “This one’s two kilogrammes over the baggage allowance,” said the young lady. “Oh,” I said, somewhat surprised. “I checked it before we left on our bathroom scales this morning and it was one kilogramme under.” “I think that may have been before I put in the toiletries,” spoke a voice from my side. Well, I didn’t really want to start emptying the contents of our suitcase in front of waiting passengers and also hold them up, so I asked how much the charge for the extra baggage would be. “It’s £6 for each extra kilogramme, so that would be £12 in total.” “I’ll pay that,” I said, glancing sweetly sideways. I presented a £20 note. “I’ll just go and get your change,” came the reply, and before I could say anything further, she was walking the length of the airport to the solitary shop. I drew a deep breath. At that point, a woman’s voice from behind me said,

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“Good morning Mr Donnelly, not the best way to start your holiday is it?” “Oh hello,” I said, turning around and trying desperately to put a name to a face and a place, “Yes, it can be difficult to pack everything you may need into your hold baggage allowance.” “I don’t think it’s fair really you know,” she continued. “I’ve only seen you twice at the hospital and in that time I’ve lost over 10 pounds in four weeks. You have to pay for the extra five pounds or so in your suitcase, but thanks to you, the plane is still going to be five pounds lighter because of the weight I’ve lost. They should be paying you for using less fuel!” “Well, thank you very much,” I said, “and very well done with your weight loss, keep up the good work.” “The thing is Mr Donnelly,” she continued, “so many people are far too heavy like me and the seats on the plane are so small that we tend to spread out onto the person next to us, so in effect, you normal weight persons get a double whammy!” I barely heard the next words from our wandering desk attendant. “Here’s your change and your boarding card Sir.” “Thank you,” I said and nodded politely to both ladies, whilst wondering how the seat allocation system worked and how next to present the idea of a ‘flying fat tax’ to the overweight and obese British Public. Footnote: Professor Dame Sally Davies, the Chief Medical Officer and self-styled ‘nation’s doctor’ recently said, “I’ve often wondered why aircraft don’t charge by total weight of the person and their luggage”. Hmm! They do in Samoa!

NHD Nov 2015 issue 109

Articles inside

dieteticJOBS

The final helping

A day in the life of

Web watch

Weight management

Dementia and nutrition

Hydration

Clinical nutrition in care homes

Critical care on the ICU

Book review

News

Sustainable protein sources