22 minute read
Weight management
exPerienCeS in PrACtiCe
alison holloway specialist community dietitian, sheffield Teaching hospitals nhs foundation Trust
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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.
the practical integration of dietetics and cognitive behavioural therapy in weight management
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 whohadothersignificantpsychologicalor psychiatric disorders, such as personality disorders and psychosis.
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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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 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
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 atalltheaspectthataffectaperson’schoicesaround 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.
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
WhAt’S neW in PAediAtriC food AllerGy?
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
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
figure 1: Map guideline flow chart13
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Table 2: Extensively hydrolysed and amino acid formulas available on prescription in the UK
feed name manufacturer protein Source lactose content
extensively hydrolysed formulas
althera sMa
aptamil pepti 1 Milupa
aptamil pepti 2 cow and gate pepti-Junior cow and gate infatrini peptisorb nutricia
nutramigen 1 lipil nutramigen 2 lipil pregestimil lipil similac alimentum Mead Johnson
abbott hydrolysed whey
hydrolysed whey contains lactose
contains residual lactose
hydrolysed casein lactose free
amino acid formulas
alfamino neocate lcp Neocate Active Neocate Advance sMa
nutricia amino acids lactose free
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
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 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).
nUTs 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
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 as the hygiene hypothesis.16 As such, there is great interest in understanding the role that pre- and 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
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.
