NHD Magazine - February 2016 by NH Publishing Ltd

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NHDmag.com

Issue 111 February 2016

Public Enemy No 1 Carrie Ruxton p12 ISSN 1756-9567 (Online)

PENG: because support and influence matter. . . p44

Anne Holdoway Registered Dietitian & Chair of PENG

PREGNANCY and NUTRITION Infant milk intolerancE FOLIC ACID critical care and obesity

dieteticJOBS • web watch • new research

REFERENCES: 1. Sampson HA et al. J Pediatr 1991;118(4):520-525. 2. Data on ďŹ le. 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

Is sugar public enemy no 1? 6

News

Latest industry and product updates

10 Introducing Emma Coates Welcome to NHDâ&#x20AC;&#x2122;s new Editor

42 IMD watch Epilepsy and Ketogenic Diet Therapy

16 Pregnancy & nutrition The role of DHA during pregnancy

44 On behalf of PENG In support of the dietetic profession

23 Infant milk intolerance An overview of paediatric milk allergy

48 dieteticJOBS

28 Folic acid fortification Reviewing the evidence

30 Critical Care Obesity and nutrition on the ICU

49 A day in the life of . . .

35 Malnutrition & the elderly The pioneering PaperWeight Armband

51 The final helping

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 Kaylee Allan, Specialist Dietitian, North Bristol NHS Trust Kirstine Farrer, Consultant Dietitian, Salford Royal NHS Dr Isabel Skypala, Consultant Allergy Dietitian Kit Kaalund Hansen, Adult Ketogenic Diet Therapy Dietitian Anne Holdoway, Registered Dietitian, Chair of PENG Belinda Mortell, Registered Dietitian, Glan Clwyd Hospital

39 Adult food allergies Causes and symptoms

NHDmag.com February 2016 - Issue 111

Latest career opportunities

Events & courses

Upcoming dates for your diary

A new BDA Council member

The last word from Neil Donnelly

Editor Chris Rudd RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dawson Design Heather Dewhurst Advertisement Sales Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk @NHDmagazine www.NHDmag.com www.dieteticJOBS.co.uk All rights reserved. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

from the editor Welcome to Issue 111 and I do hope that the New Year has been a happy and healthy one so far.

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.

Many of you may be busy planning for the Nutrition and Hydration week from 14-20 March and I do hope that some of you will be entering into the record breaking world cream tea party on Wednesday 16 March. 2016 for NHD also offers you exciting developments. In a new column from the Parenteral and Enteral Nutrition Group (PENG) of the British Dietetic Association (BDA), Chair, Anne Holdoway shares PENG: because support and influence matter, providing us with an overview of the plethora of projects that are being undertaken by the PENG Committee, Clinical Leads and members. One of PENG’s resources is the Managing Adult Malnutrition in the Community guide and pathway and that links nicely with another article by Kirstine Farrer that informing us of a pioneering non-medical, non-intrusive tool that is helping health and social care professionals to identify people at risk of malnutrition and signpost them to information and advice. Find out all about it in Malnutrition in the elderly: identifying and signposting with the PaperWeight Armband. Issue 111 takes us through all the major life stages from pregnancy, infant feeding, adult allergies and into elderly nutrition. We cover obesity too, with Kaylee Allan’s article on Feeding critically ill obese patients which gives us a review of the available evidence and

summarises key points to consider when assessing the nutritional requirements in the critical ill obese. If you are interested in adult food allergy, Dr Isabel Skypala tells us more in Food Allergy in Adults, while keeping with the allergy theme, in our paediatric section we also revisit Infant milk intolerance and allergy: are you sure? by Emma Coates. Another new section starting in this issue is IMD Watch - in association with the NSPKU. We welcome Kit Kaalund Hansen, the first NHS funded Ketogenic Dietitian for adults with epilepsy in the UK and her article Epilepsy and Ketogenic Diet Therapy: Managing expectations in patients will tell you more. Finally, as I reflect back over the years, I joined NHD at Issue 41 and have seen the magazine grow and develop over those years. Now is the time for me to say ‘Goodbye’ as I sign off from NHD. I would like to say an enormous thank you to all of you who have accepted my invitation to write for us - there have been seven years of excellent articles. My thanks also go to the NHD Team for their support. Emma Coates will take over from me from the next issue, so please look out for her invitations to you to write for NHD. I wish you all well and please enjoy our magazine and all the resources on offer for years to come. I feel that I know many of you, so do keep in touch and let me know of all the great work that you are doing.

The NHD Team would like to thank Chris Rudd for all her work, help and advice over the years. Her role as Editor, and Clinical Editor before that, has enabled NHD to forge forward, providing our readers with informative articles from experts in their field and giving the magazine a true dietetic focus. We wish Chris all the best in her retirement. NHDmag.com February 2016 - Issue 111

news

Food for thought

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

In the US, new dietary guidelines are required under the 1990 National Nutrition Monitoring and Related Research Act, which specifies that every five years, the US Departments of Health and Human Services (HHS) and of Agriculture (USDA) must publish a joint report containing nutritional and dietary information and guidelines for the lay public. This report itself must be based on current scientific and medical evidence. Based on these requirements, the new 2015-2020 Dietary Guidelines for Americans were released this January. These have been developed for policymakers and health professionals and relate to how the general public, aged two years and older, can improve their overall eating patterns. The guidelines provide five main overarching points developed with the intention of helping to encourage individuals make shifts in their food and beverage patterns. These are to: 1) Follow a healthy eating pattern across the lifespan; 2) Focus on variety, nutrient density, and amount; 3) Limit calories from added sugars and saturated fats and reduce sodium intake; 4) Shift to healthier food and beverage choices, and 5) Support healthy eating patterns for all. Within these, it is also specified that a healthy eating pattern both ‘includes’ and ‘limits’ the inclusion of certain foods. These recommendations are shown below. A HEALTHY EATING PATTERN

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

INCLUDES

LIMITS

A variety of vegetables from all of the subgroups: dark green, red and orange, legumes (beans and peas), starchy, and other. Fruits, especially whole fruits. Grains, at least half of which are wholegrains. Fat-free or low-fat dairy, including milk, yoghurt, cheese, and/or fortified soy beverages. A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds and soy products. Oils.

Saturated fats and trans fats, added sugars, and sodium. Key recommendations that are quantitative are provided for several components of the diet that should be limited. These are to: consume less than 10% of calories per day from added sugars; consume less than 10% of calories per day from saturated fats; consume less than 2,300 milligrams (mg) per day of sodium; if alcohol is consumed, consume in moderation - up to one drink per day for women and up to two drinks per day for men and only by adults of legal drinking age.

Overall, most of these guidelines make good common sense. However, we can already see some discrepancies with new UK alcohol guidelines which further advise to spread alcohol intake over three days or more if as much as 14 units per week are being consumed. The new report also highlights the need for global consistency when it comes to referring to sugars. We see the term ‘added sugars’ used here, whilst the latest UK Scientific Advisory Committee on Nutrition Carbohydrates and Health report replaces this with ‘free sugars’. For more information • US Department of Health and Human Services and US Department of Agriculture (2016). 2015-2020 Dietary Guidelines for Americans. 8th Edition. Available at http://health.gov/dietaryguidelines/2015/guidelines/ • Department of Health (2016). UK Chief Medical Officers’ Alcohol Guidelines Review Summary of the proposed new guidelines. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/ file/489795/summary.pdf • SACN (2015). Carbohydrates and Health. TSO: London https://www.gov.uk/government/uploads/system/ uploads/attachment_data/file/445503/SACN_Carbohydrates_and_Health.pdf

NHDmag.com February 2016 - Issue 111

news Latest on pregnancy weight gain Excess pregnancy weight gain is a growing problem. In turn, this has been linked to more challenging deliveries, with more C-sections being required due to the larger birth size of infants. Now, a new systematic review has looked into the role that macronutrients play in this. After searching eight different scientific databases, 56 articles (46 observational studies and 10 trials) were found, although only 11 (20%) were regarded to be ‘high quality’. Twelve studies suggested that higher energy intakes could be associated with higher levels of pregnancy weight gain. Some trends were seen for fat, although more work is needed to look into the specific roles of individual types of fat and no trends were found for carbohydrate or protein. Overall, these findings indicate that energy intakes appear to be associated with levels of pregnancy weight gain, although better quality trials now need to feed into future pooled analyses.

Fatty acid discrepancies A wealth of research has measured levels of fatty acids in relation to disease biomarkers. Now it has come to light that different approaches in doing this affects association patterns. Using data from two human cohorts, new work examined relationships between blood lipids (TAG, and LDL, HDL or total cholesterol) and circulating fatty acids expressed either as a percentage of total, or as concentration in serum. Overall, it was found that correlations between stearic acid, linoleic acid, dihomo-γ-linolenic acid, arachidonic acid, docosahexaenoic acid and circulating TAG reversed when fatty acids were expressed as concentrations compared with a percentage of total. This reversal pattern was also seen in blood serum samples from both human cohorts. In summary, it seems that different methods of expressing fatty acids can lead to dissimilar correlations between blood lipids and certain fatty acids. Worryingly, this study raises important questions about how reversals in association patterns could affect the interpretation of findings from such studies.

Nutr Vol 103, No 1, pg 83-99.

115, No 2, pg 251-61.

For more information, see: Tielemans MJ et al (2016). Am J Clin

Sugar reduction - a pleasant surprise There was much in the public domain last year about sugar, with interest about how to put sugar reduction guidelines into practice. Now, new work has looked into whether we can get used to having less sugar in our diets, in a similar way to how we become used to using less salt. A sample of healthy adults (n=29) aged 21-54 years were studied for one month and matched across groups for their baseline sugar intake and weight. They were then randomly allocated to: 1) eat a low sugar diet for three months (40% of calories from simple sugars were replaced with fat, protein or complex carbohydrate), or 2) no

For more information, see: Sergeant S et al (2016). Br J Nutr Vol

change in sugar intake. For the last month of the study they ate as they wished. Overall, results showed that reducing dietary intakes of simple sugars altered perceived ‘sweet taste intensity’. Interestingly, even when sugar intakes were reduced, perceived ‘pleasantness’ was unaffected. Sweetness variations in beverages, however, were not as well identified. These results indicate that sugar reduction does appear to influence perceived sweet taste intensity. More work is needed to determine how this may affect long-term consumption habits.

For more information, see: Wise PM et al (2016). Am J Clin

Nutr Vol 103, No1, pg 50-60.

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news GSE for high blood pressure? Grape seed extract (GSE) is a rich source of proanthocyanidins (a class of polyphenols with antioxidant properties), but until recently, their potential health benefits has not necessarily been reinforced with scientific evidence. Now, a new study has looked at potential effects on blood pressure. A 12-week randomised controlled trial allocated 36 middle-aged adults with early stages of hypertension to drink a juice containing 150mg GSE twice daily for six weeks, or a placebo juice (no GSE). This included a two-week placebo run-in period and a four-week no beverage follow-up period. Results showed that after six weeks, GSE significantly lowered systolic blood pressure by 5.6% and diastolic blood pressure by 4.7%. Unfortunately, blood pressure returned to normal four weeks after the beverage was discontinued. Overall, these results indicate that GSE could help to lower blood pressure in high risk individuals. Further trials are now needed to see if other population groups could also benefit.

For more information, see: Park E et al (2016). Br J Nutr Vol

115, No 2, pg 226-38.

Iron intakes of toddlers Iron deficiency is common amongst toddlers and children and is regarded as the most common nutritional deficiency worldwide. Now, new work in Australia has measured habitual iron intakes amongst those aged two years and under - a population group that is often overlooked from dietary surveys. Data from the Melbourne Infant Feeding, Activity and Nutrition Trial Program was analysed from 485 infants (mean age 9.1 months) and 423 toddlers (mean age 19.6 months) and their mums. Interestingly, mean iron intakes were found to be 9.1mg/day for infants, declining to 6.6mg/ day for toddlers. Subsequently 32.6% of infants and 18.6% of toddlers had inadequate daily iron intakes. The main sources of iron were fortified infant formula and cereals. This data emphasises the need to support families in helping to maintain and improve children’s iron intakes. The decline in formula use as children get older appears to correlate with the decline in habitual intakes.

For more information, see: Atkins LA et al (2016). Br J Nutr Vol

115, No 2, pg 285-93.

NHDmag.com February 2016 - Issue 111

product / industry news

Important News for VitasavouryTM 200

Vitaflo® International Ltd wishes to inform you that Vitasavoury 200 has been discontinued from our nutrition support product range. Vitasavoury 300 is available as an alternative in all four flavours. For more information please contact your local Vitaflo representative or call the nutrition helpline on 0151 702 4937. www.vitaflo.co.uk

Making life taste good with improved Althéra®

In November 2015, Nestlé Health Science reformulated Althéra®, for the dietary management of mild to moderate cows’ milk allergy. Improved Althéra® has preferred taste and palatability for increased acceptance of the formula.1 The 100% extensively hydrolysed whey protein source provides a more palatable option compared to casein based eHF.2 • Enhanced level of calcium which is needed for normal growth and development of bone.3 • Contains lactose which significantly increases the absorption of calcium and improves palatability.4,5 • Hypoallergenic for better tolerance - the most extensively hydrolysed formula in the UK.2 • 100% extensively hydrolysed whey protein source facilitates faster gastric emptying.6,7 and provides a more palatable option compared to casein based eHF.2,5 Careline: 0800 0 81 81 80 ROI: 1800 931 832 Email: SMA.Information@uk.nestle.com Website: www.smahcp.co.uk References: 1. EFSA Journal Scientific opinion. 2014. Scientific Opinion on the essential composition of infant and follow-on formulae. EFSA Panel on Dietetic Products, Nutrition and Allergies page 40. 2. Abrams SA et al, Am J Clin Nutr. 2002;76(2):442-6. 3. Niggemann B et al. Pediatr Allergy Immunol 2008; 194(4):348-54. 4. Rapp et al. Clin Transl Allergy 2013; 3 (suppl 3):132. 5. Fried MD et al. JPediatr 1992; 120:569-572. 6. Khoshoo V et al. Eur J Clin Nutr 2002; 56:656-658. 7. Althéra versus Nutramigen competitive benchmarking test – Sweden 2012 (internal data).

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Dialachemist are a Lancashire based, fully General Pharmaceutical Council (GPhC) regulated online pharmacy. We are Version 1 working with them to bring you this UK Date 23/10/2015 based home delivery service. To register for this service you must speak to your dietitian. They can register you so you can order your favourite Mevalia products whenever you need them. You can ďŹ nd more information about this service on our website:

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Introducing NHD’s new Editor, Emma Coates… Emma will be taking up the post of NHD Magazine’s Editor from the March issue and here she tells us a bit about her dietetic background and what she hopes for the future of NHD. It’s great to have you on board Emma. Can you give us a brief outline of your dietetic background? I studied for my BSc (Hons) in Dietetics at Leeds Metropolitan University, graduating in 2006 and was fortunate to find my first job that year, at the Countess of Chester Hospital. For around two and a half years I worked there as a Band 5 Dietitian, completing an excellent rotation through many specialisms, including surgical, cardiology, respiratory, renal, diabetes and my personal dietetic interest, paediatrics. In 2008, a Band 6 paediatric position opened up at Wrexham Maelor Hospital, part of the Betsi Cadwaladr University Health Board (BCUHB) trust in North Wales, in my hometown. I jumped at the chance and applied. The following six years provided a large and varied paediatric caseload to manage in both the hospital and community setting. Whilst at BCUHB, I embraced many opportunities to develop and expand my skills as a dietitian, including becoming part of the student training team, a BDA trade union representative, writing for NHD Magazine and guest lecturing for the University of Chester. After eight and half years of working as an NHS dietitian, I moved into industry as metabolic dietitian/ brand manager for Dr Schar - Mevalia Low Protein. This is an exciting and challenging role where I manage the low protein brand for the company in the UK. My first year there been extraordinary, developing so many new skills and expanding my knowledge greatly. I have no doubt that this next year with the company will bring even more opportunities to grow as a dietitian. What are the hot topics in dietetics at present? Depending on your specialism, anything can be a hot topic! However, the nutritional challenges at either end of the life span are always talking points. Getting the best nutritional start in life is vital, as seen by the evidence from the www.thousanddays.org campaign. In contrast, the management of elderly care nutrition is a key issue to discuss, as the ageing population is ever increasing. Keeping our nation healthy is always a source of great debate, whether 10

NHDmag.com February 2016 - Issue 111

it’s related to malnutrition (under nutrition) or the obesity/metabolic syndrome crisis. Amongst these discussions, there’s always the nitty gritty of how dietetics can offer efficient, effective, safe and value-for-money services. In the future, I see further developments in the use of ketogenic diets and possibly the role of nutrigenomics. How do you see the NHD community supporting healthcare professionals in the field of nutrition and dietetics? Over the years, NHD has been a great provider of current and relevant articles for the nutrition and dietetics community. Keeping abreast of hot topics and moving with the current trends, NHD is a good tool for topping up on the most recent information, research and guidelines in all things nutrition and dietetics. It provides an easy way for dietitians and nutritionists to complete some CPD, learn something new, or just reinforce their current knowledge. Now, with excellent regular columns from contributors such as PENG and the NSPKU (IMD watch), as well as the great quality and variety of individual contributors we have, CPD has never been so easy or enjoyable! What’s your vision for NHD as you take over the role of Editor? I am keen for all of the magazine’s current accolades to continue, but also to welcome new contributors, giving more dietitians, nutritionists and other healthcare professionals an opportunity to develop their skills as writers and share their information, experiences and best practice. If you have an interest in writing for NHD, please email info@networkhealthgroup.co.uk. We would love to hear from you. Expanding our readership is important for me. Opening up NHD to students, dietetic assistants/technicians and nutritionists will hopefully encourage a new group of readers to enjoy all that NHD has to offer. Interaction with our readers is important; creating discussion and gaining feedback is key to the magazine’s ongoing success.

AD SPACE From birth to discharge and beyond, the ESPGHAN-compliant1 Nutriprem range is designed to aid the development of preterm babies. For products that support feeding with breastmilk and contain ingredients to help babies thrive, choose Nutriprem.

Important notice: Breastmilk is best for babies. Nutriprem Breastmilk Fortiﬁer is a nutritional supplement designed to be added to expressed breastmilk for feeding preterm and low-birthweight infants. Nutriprem Protein Supplement, Hydrolysed Nutriprem, Nutriprem 1 and 2 are foods for special medical purposes. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed Nutriprem, Nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low–birthweight infants. Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50:85–91.

COVER STORY

Is sugar public enemy No 1?

Carrie Ruxton PhD, Freelance Dietitian

Sugar has dominated the news for more than a year, leaving dietitians wondering how the revised targets will be achieved, given the chasm between current and recommended intakes. Should sugar be a special focus of public health nutrition, or would the public benefit more from messages that put sugar into the context of a healthy balanced diet? Is there any need for sugar in the diet at all? This article will consider these points. Since 1994, sugar recommendations have been couched as non-milk extrinsic sugars (NMES) and set at a limit of 10% daily energy.1 However, in 2015, the Scientific Advisory Committee on Nutrition (SACN)2 halved this to 5% of daily energy, equating to no more than 30g sugar per day for an average person over 11 years. In addition, the classification of non-milk extrinsic sugars was changed to free sugars, defined as all mono- and disaccharides added during processing or cooking, plus the sugars naturally present in honey and fruit juices. These recommendations put the UK in line with a 2015 WHO report.3 New recommendation

Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods.

The new recommendation was based on evidence from randomised controlled trials where sugar consumption had been increased deliberately, mainly by giving participants additional sugar-sweetened soft drinks (SSSD). The results typically showed that higher intakes of free sugars were statistically correlated with an increase in daily energy intakes. In one study, the baseline diet contained less than 5% energy from sugars as well as a lower amount of energy. SACN therefore concluded that cutting average intakes in the UK to less than 5% energy from free sugars would result in a fall in daily energy of around 100kcal. Interestingly, while SSSD consumption was associated with higher body mass index, weight gain and an increased risk of Type 2 diabetes in cohort studies, no

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such relationships were found between these outcomes and free/added sugar intake. This suggests that added sugars in liquid form may be more detrimental than sugar present in foods, possibly because of their higher glycaemic load and lesser impact on appetite. Both free sugars and SSSD were consistently found to be a risk for dental caries in children, but not in adults. There was insufficient evidence to link sugar or SSSD consumption with cardiovascular disease or associated risk factors, such as blood pressure, blood lipids or glucose tolerance. SACN summary • • •

• •

Dental caries linked to added/free sugars and SSSD intakes Energy intake linked to added/free sugars and SSSD intakes Body mass index, weight gain in children and Type 2 diabetes linked to SSSD, not sugars No links between added/free sugars and cardio-metabolic outcomes No links between cardiovascular disease and SSSD

Intakes and sources

Current intakes of sugar, from the National Diet and Nutrition Survey, suggest that the new recommendations will be challenging to implement. As Figure 1 shows, adults consume an average of 11% energy from NMES while children’s diets contain around 15%. Males typically eat more sugar than females.

Public Health: Sugar Figure 1: Average daily NMES intakes

% total energy from NMES

18 16 14 12 10

Male

Female

6 5% energy

4 2 0

4-10y

11-18y

19-64y

65+y

Key: NMES, non-milk extrinsic sugars; y, years. Source: Bates et al (2014)4

As presented in Figure 2, the top sources of NMES in childrenâ&#x20AC;&#x2122;s diets are drinks, desserts and confectionery, while adults obtain a significant amount from drinks, including alcohol, sugar and preserves. Biscuits, cakes, sugar and preserves are major providers of NMES in older adults. In teenagers, drinks provide more than 40% of daily sugar intakes.

Action needed

To lower intakes of free sugars, dietitians need to target specific food categories that provide a significant proportion of sugar in the diet. This could include advising reductions in SSSD and alcoholic drink consumption, switching from sugar-containing to sugar-free drinks, limiting portions and frequency of confectionery, biscuits,

Figure 2: Contributors to daily intakes of NMES

100%

% contribution to daily intakes of NMES

90% 80%

Other foods

70%

Breakfast cereals

60%

Desserts Biscuits & cakes

50%

Confectionery

40%

Sugar and spreads

30%

Alcoholic drinks

20%

Soft drinks

10%

Fruit juice

0% 1.5-3y 4-10y 11-18y 19-64y

65+y

Key: NMES, non-milk extrinsic sugars; y, years. Source: Bates et al (2014)4 NHDmag.com February 2016 - Issue 111

Public health: sugar cakes and desserts and discouraging the addition of sugar to foods and drinks in the home. Such advice would be consistent with promotion of a healthy balanced diet as set out in the EatWell plate and other food-based dietary guidelines. Reformulation would also need to play a role in lowering sugar levels in commonly-eaten foods. Where this is not technically possible, for example in baked goods and specialist confectionery, portion sizes should be lowered. Price promotions should also be addressed to avoid incentivising excess purchasing of high sugar options. Kantar data5 show that 40% of foods on promotion are categorised as ‘HFSS’, i.e. high fat, sugar or salt, and that promotions significantly influence purchasing behaviour. The BDA should consider lobbying government and industry for a voluntary or regulatory change. The British Nutrition Foundation recently published a sample seven-day meal planner6 based on an adult achieving all dietary guidelines, including the new ones for sugar and fibre. The plan contains eight portions of fruit and vegetables daily, but only two alcohol drinks and two portions of ‘treat’ foods weekly. Fruit juice is limited to five servings a week and there are no SSSD. The sample plan is just one way of achieving dietary guidelines, but it nevertheless represents a huge shift from current intakes where around 25% of daily energy comes from discretionary foods. Are all sugars equal?

While some researchers have expressed concerns about dietary fructose and liver fat, SACN only differentiated in health terms between free sugars, i.e. added to foods or in honey/fruit juice, and those naturally present in fruits or dairy foods. However, dental researchers have challenged whether sugars in fruit juice are any more cariogenic than sugars in fruit, as the latter is normally chewed, thus releasing the sugars in the oral cavity.7 The idea that lactose

added to a food is more dangerous than lactose naturally present also seems incongruous, and it is notable that free sugars are chemically identical to natural sugars. Further research will refine the new sugar guidelines so that consumers get the most effective advice. The only information available at point of purchase is food labels which, by law, declare total sugars. This means that foods high in natural sugars, due to their fruit or dairy content, may seem unhealthy when, in fact, they do not count as a source of free sugars. Consumers may need help to differentiate between sugar-containing foods that are acceptable and those which need to be eaten sparingly. This is why a holistic approach looking at the overall nutritional content of a food or drink, rather than simply its sugar content, would be a better approach. Unintended consequences of a narrow focus on sugar may include consumers avoiding ‘high’ sugar foods which are rich in fruit or switching to low sugar snacks that are high in fat and calories. As sugar is often used to improve the palatability of high fibre products, such as breakfast cereals or cereal bars, sugar avoidance may encourage consumers to choose lower sugar, lower fibre options. Conclusion

The gap between current sugar intakes and the new target is so large that reformulation alone is unlikely to be enough. People wishing to achieve less than 5% energy from free sugars would have to give up eating several categories of foods and drinks, and severely limit intakes of others. This may not be achievable for most, partly due to the limitations of food labelling. Dietitians need to consider whether sugars are so detrimental to health that a monumental shift in eating patterns is justified. Alternatively, they may consider that food-based dietary guidelines, which stress a holistic dietary view, are a more effective and achievable option.

References 1 Committee on Medical Aspects of Food Policy (COMA) (1994). Dietary Reference Values. London: HMsO 2 scientific Advisory Committee on Nutrition (sACN) (2015). Carbohydrates and health. London: sACN. www.gov.uk/government/publications/sacncarbohydrates-and-health-report 3 world Health Organisation (2015). sugars intake for adults and children. www.who.int/nutrition/publications/guidelines/sugars_intake/en/ 4 bates b et al (2014). National Diet and Nutrition survey; rolling programme years 1-4. London: FsA/PHE 5 Kantar (2014). presented at Food and Drink Innovation Network conference. www.fdin.org.uk/events/#/downloads 6 british Nutrition Foundation (2015). sACN guidelines meal planner. www.nutrition.org.uk/nutritioninthenews/headlines/872newrecommendationsfibresugars.html 7 Issa AI et al (2011). Comparison of the effects of whole and juiced fruits and vegetables on enamel demineralisation in situ. Caries Res 45: 448-452

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BREASTFEEDING IS BEST FOR BABIES

Science & nature

hand in hand

AD SPACE From the leading experts in organic infant nutrition, comes the UK’s lowest protein infant milk. Ours is the first infant milk in the UK to contain less than 2g/100kcal protein, making the protein level and quality closer to that found in breastmilk1. High protein intake in the first two years of life has been linked with an increased long term risk of being overweight or obese2. All the natural benefits of organic, coupled with 50 years of breastmilk research – and still costs less than the leading brand.3

Discover more at hipp4hcps.co.uk @hipp_for_hcps 1 Contains 1.89g/100kcal of protein, including _-lactalbumin, making the protein level and quality closer to that found in breastmilk (1.7g/100kcal). Nommsen LA et al. Am J Clin Nutr 1991; 53: 457–465. 2 Koletzko B et al. Am J Clin Nutr 2009; 89(5):1502S–8S. 3 Price per 100g of infant milk powder: HiPP £1.06, Aptamil £1.11. Price per case of 24 infant milk hospital formula: HiPP £8.36, Aptamil £8.84. Prices correct as at April 2015. Important Notice: Breastfeeding is best for babies. Breastmilk provides babies with the best source of nourishment. Infant formula milks and follow on milks are intended to be used when babies cannot be breastfed. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle feeding may reduce breastmilk supply. The financial benefits of breastfeeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Infant formula and follow on milks should be used only on the advice of a healthcare professional.

PREGNANCY & NUTRITION

DoCoSAHExAEnoIC ACID AnD ITS PRInCIPAL RolES DuRIng PREgnAnCy Docosahexaenoic acid (DHA) is an important dietary component, yet there is a general tendency for it to be under-consumed during pregnancy. This is particularly concerning given the growing evidence base that links DHA to fetal development. This article reviews current DHA pregnancy intakes, guidelines and the evidence base focusing on DHAâ&#x20AC;&#x2122;s role in fetal/infant brain and eye development. 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.

Docosahexaenoic acid (DHA) is an Omega-3 (n-3) polyunsaturated fatty acid that cannot be produced efficiently by the body, yet is essential to life. Subsequently, it is needed from other sources, namely fish and fish-oil products.1 Metabolically, DHA can be produced by the body (Figure 1), but only in very small amounts with isotope studies suggesting that its conversion from the parent fatty acid alpha-linolenic acid (ALA) into eicosapentaenoic acid (EPA) and then DHA is no more than 5.0% and probably no more than 1.0% amongst adults following Western diets.2 As shown in Figure 1, the Omega-6 (n-6) and n-3 acids share the same metabolic pathway and use of the same enzymes. Subsequently, higher dietary intakes of n-6 fatty acids skew the metabolic pathway in the direction of forming more arachidonic acid and away from the synthesis of EPA and DHA.3 While our ancestors once followed a diet providing a balanced 1/1 ratio of n-6: n-3 fatty acids, this has changed over time. In modern times, increased consumption of vegetable oils has now resulted in a 20-25/1 ratio of these fatty acids, with subsequent reductions in DHA production by the body; a process that is already limited.3,4 Dietary sources of n-3 fatty acids (per 100g of food eaten) include walnuts (7.5g), mackerel (5.6g), kippers (3.4g), herring (1.8g), sea bass (1.7g), chicken (1.4g), almonds (0.3g), eggs (0.1g).5 Looking at these figures, it can be seen that the n-3 polyunsaturated fatty acid

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content of foods is highly variable, although oily fish is a particularly good source. Unfortunately, during pregnancy, there is a general tendency for mothers to avoid eating oily fish, with concerns about mercury and other contaminants contributing to this.6 A dislike for the taste of fish may further contribute to low fish intakes and inadequate intakes of the n-3 fatty acid DHA. Recommendations

The European Food Safety Authority (EFSA) has set an adequate intake (AI) target of 250mg of EPA plus DHA for adults. Further to this, an additional 100-200mg DHA has been advised for pregnancy and lactation to compensate for maternal dietary oxidative losses of DHA and to account for growing stores needed by the foetus/infant.7 Work by Koletzko and colleagues forms the basis of the International Society for the Study of Fatty Acids and Lipids (ISFAAL) statements and recommendations.8 These guidelines have been published in two scientific journals which advise that pregnant and lactating women should obtain at least 200mg per day of DHA from dietary sources,9,10 although up to 1.0g per day DHA has been used safely in randomised clinical trials.9 Considering the dietary intakes and conditions of Asian populations, a systematic review of 78 randomised controlled trials concluded that pregnant Asian women should achieve an extra â&#x2030;Ľ200mg DHA per day, ideally striving for

PREGNANCY & NUTRITION Figure 1: Metabolic endogenous production of DHA

Interestingly, 43% of women took dietary supplements in week 20 and 39% in week Omega 3 Omega-6 Shared enzymes pathway 30 of pregnancy, with multivitamin use pathways pathway being most common.12 Alpha-linolenic Linoleic acid The Canadian Alberta Pregnancy acid 6-desaturase Outcomes and Nutrition (APrON) cohort measured DHA intakes during each Gamma-linolenic Stearidonic acid acid trimester of pregnancy and after birth. Elongase Researchers found that only 27% of women Eicosatetraenoic Dihomo Gammaduring pregnancy and 25% of mothers acid linolenic acid three months after birth met European Union DHA recommendations.13 Earlier Eicosapentaenoic Arachidonic acid acid Canadian work reported even lower mean DHA intakes: 160mg per day derived Docosapentaenoic from food frequency questionnaire data acid collected during weeks 28 and 35 of Docosahexaenoic pregnancy.14 acid In Mexico, median DHA intakes Source: Adapted from Ruxton et al3 amongst women (aged 18-35 years) interviewed 18-22 weeks into their a total intake ≥300mg DHA per day. The review also pregnancies were 55mg per day. While eggs, concluded that higher intakes of 600-800mg DHA chicken and fresh and canned fish were the main per day could provide greater protection against contributors to DHA intakes, these were more early preterm births in this population group.11 likely to be eaten by women who had completed high school. It was also concluded that the high DHA intakes n-6:n-3 ratio of the diets of these women was As shown in Table 2, a number of studies have likely to over-ride any possible n-3 benefits.15 measured DHA intakes in pregnancy. European Work conducted in China showed that DHA research highlights variations in DHA intakes, intakes during pregnancy vary geographically. with Spanish women tending to have some Those living in coastal regions (n=42) had higher of the highest and German mothers some DHA intakes (93.9mg per day) compared with of the lowest median daily DHA intakes.12 those living inland (n=40) who had intakes of Table 1: DHA recommendations for pregnancy Reference

Country

DHA

EFSA (2010)7

European focus

Total intake 350-450mg DHA/day 250mg/day EPA+DHA and an extra 100-200mg/day preformed DHA during pregnancy and lactation.

Koletzko et al (2007)9

European focus

Total intake ≥200mg DHA/day Pregnant and lactating women should aim to achieve dietary intakes of 200mg DHA/day. Intakes of up to 1.0g/d DHA or 2.7g/day n-3 long-chain PUFA have been used in RCTs without significant adverse effects.

Koletzko et al (2008)10

European focus

Total intake ≥200mg DHA/day Pregnant and lactating women should aim to achieve an average intake of at least 200mg/day DHA.

Koletzko et al (2014)11

Asian perspectives

Total intake ≥200mg DHA/day Additional supply ≥200mg DHA/day, usually achieving a total intake ≥300mg DHA/day.

Key: EFSA, European Food Safety Authority; DHA, docosahexaenoic acid. NHDmag.com February 2016 - Issue 111

PREGNANCY & NUTRITION Table 2: DHA intakes in pregnancy Study & Country

Methods

DHA intakes

Main findings

Franke et al (2008)12 Europe

FFQ in weeks 20 & 30 of pregnancy (n=62)

155mg/1000kcal wk20 - Spain 161mg/1000kcal wk30 - Spain 119mg/1000kcal wk20 - Germany 124mg/1000kcal wk30 - Germany 122mg/1000kcal wk20 - Hungary 125mg/1000kcal wk30 - Hungary

DHA intakes varied across the European cohorts.

Jia et al (2015)13 Canada

24-hour dietary recalls used in the APrON cohort (n=600)

159mg/d - 1st trimester 187mg/d - 2nd trimester 237mg/d - 3rd trimester 186mg/d - Postpartum

Only 27% women during pregnancy and 25% women met the EU DHA recommendation.

Innis et al (2003)14 Canada

FFQ at weeks 28 and 35 of pregnancy (n=55)

160mg/d (range: 24 to 524mg/d)

DHA intakes were low amongst pregnant women which could have functional significance.

Parra-Cabrera et al (2011)15 Mexico

Retrospective FFQ at weeks 18-22 pregnancy from the previous 3 months (n=1364)

55mg/d and an omega 6:3 ratio of 12:1

DHA intakes were lower than recommended values.

Zhang et al (2013)16 China

DHA intakes measured amongst different geographical regions (n=123)

93.9mg/d in the coastal group 41.8mg/d in the river/lake group 41.1mg/d in the inland group

DHA intake ranged between geographical regions.

Dwarkanath et al (2009)17 South India

FFQ measuring DHA in all three trimesters (n=829)

11mg/d (median intake)

Dietary interventions are needed to improve DHA intakes.

Zhao et al (2013)18 Canada

FFQ at weeks 24-28 of pregnancy (n=307)

100mg/ d (median intake)

More than 90% of women had DHA intake <300mg/d.

Key: APrON, Alberta Pregnancy Outcomes and Nutrition cohort; DHA, docosahexaenoic acid; EU, European Union; FFQ, food frequency questionnaire.

just 41mg per day.16 Equally, work carried out in South India during pregnancy (n=829) showed that DHA intakes increased with each trimester, with median intakes being particularly low at 11mg per day.17 Zhao and colleagues (2013) assessed the alterations in plasma fatty acid concentrations during the third trimester of pregnancy and the effects of food intakes at 24-28 weeks gestation.18 The median intake of DHA was only ~100mg per day, although dietary intakes of DHA were positively and significantly associated with plasma DHA levels. Plasma DHA levels decreased significantly from weeks 24-28 to 32-35, suggesting 18

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maternal DHA depletion in the third trimester of pregnancy in this Canadian cohort.18 At this point, it should also be considered that while continued research is needed to determine DHA intakes in pregnancy, suitable biomarkers should also be used alongside dietary assessment tools. For example, DHA levels present in plasma, cell membranes and adipose tissue would all add to the comprehensiveness of future investigations.19 Role(s) of DHA in pregnancy

n-3 fatty acids are important during pregnancy as these are transferred through the placental

PREGNANCY & NUTRITION Table 3: RCTs focusing on brain development Study & Country

Methods

Findings

Jensen et al (2010)23 US

RCT from delivery until four months after birth (n=119). Women received 200mg/d DHA algal oil or a vegetable oil. Cognitive and visual tests at five years of age.

Infants receiving DHA performed significantly better on sustained attention tasks (p<0.008).

Jensen et al (2005)24 US

RCT from delivery until four months after birth (n=227). Women received 200mg/d DHA algal oil or a vegetable oil. Infant tests up to 30 months of age.

DHA supplementation was found to improve the Bayley Psychomotor Development Index at 30 months of age (p<0.01).

Judge et al (2007)25 US

DB PC RCT (n=29). Ate a functional food containing 300mg DHA per bar (five bars per week) or placebo from 24 weeks pregnancy until delivery. Infant cognitive tests at nine months.

DHA bar ingestion significantly improved performance of problem-solving tasks (p=0.017), but not memory recognition.

Helland et al (2003)26 Norway

DB RCT (n=341). Women took cod liver oil containing 803mg/10mL DHA from week 18 pregnancy until delivery, or a corn oil placebo. Infant cognitive tests at six and nine months.

Children born to mothers taking cod liver oil had higher mental processing scores. Childrenâ&#x20AC;&#x2122;s IQ scores at age four years also correlated positively with maternal DHA intake.

Van Goor et al (2011)27 Netherlands

DB PC RCT (n=114). Women took: 1) 220mg/d DHA, 2) 220mg/d DHA+AA or 3) placebo from 14-20 weeks pregnancy until delivery. Neurodevelopment tests at 18 months.

Children with minor neurological dysfunction had lower umbilical venous DHA. Short-term DHA supplementation did not improve any other neurodevelopment outcomes.

Gould et al (2014)28 Australia

RCT (n=185) infants born to mothers who took 800mg/d DHA or placebo from 20 weeks pregnancy until after birth.

Maternal supplementation was not found to improve attention or the working memory of offspring.

Key: AA, Arachidonic acid; DB, double-blind; DHA, docosahexaenoic acid; IQ, Intelligence Quotient; RCT, randomised controlled trial.

and milk supply, subsequently impacting on fetal/infant brain and visual function.20 DHA also has unique structural properties which provide optimal conditions for cell membrane functions, which includes the grey matter of the brain and visual pathways.21 Given this, DHA is important for normal brain and retinal tissue development tissues (especially myelin and retinal photoreceptors). It is also needed for normal neurotransmission and connectivity.6 In fact, DHA found in the nervous tissue and retina contributes to over 90% of all n-3 fatty acids.22 The next section of this article evaluates evidence from RCTs focusing on the role of DHA supplementation during pregnancy and lactation in relation to brain and eye development. Brain development

Due to the rapid growth of nervous tissue, both foetuses and newborns have high DHA require-

ments. Studies measuring DHA concentrations in the brain show a continuously increasing uptake of DHA - starting from the 22nd week of pregnancy through to the early years of a childâ&#x20AC;&#x2122;s life.22 A PubMed search identified six RCTs studying the effects of DHA supplementation on brain development. Four of these studies reported positive findings, with most interventions taking place in the third trimester, running into or after delivery (Table 3). Jensen and colleagues undertook two trials. DHA derived from algal oil (200mg per day) was associated with infants performing significantly better on sustained attention tasks23 and Bayley Psychomotor Development Index (a measure of infant development)24 when taken from delivery for four months after birth. Other work used either functional foods providing DHA (300mg per bar), or cod liver oil containing DHA (803mg per 10ml). The ingestion of five functional bars per week from NHDmag.com February 2016 - Issue 111

PREGNANCY & NUTRITION Table 4: RCTs focusing on eye development Study and country

Methods

Findings

Dunstan et al (2008)29 Australia

DB PC RCT(n=98) pregnant women received 2.2g DHA, 1.1g EPA or olive oil from 20 weeks gestation until delivery.

Children in the fish oil-supplemented attained a higher score for eye and hand coordination score than the placebo group (p=0.021).

Judge et al (2007b)30 US

DB PC RCT (n=30). Ate a functional food containing 300mg DHA per bar (five bars per week) or placebo from 24 weeks pregnancy until delivery. Visual tests on infants at four and six months.

DHA supplementation significantly improved infant visual acuity at four months (p=0.018).

Malcolm et al (2003)31 UK

RCT (n=100) pregnant women received fish oil or an oleic acid placebo supplement from 15 weeks until delivery. Infant retinal development assessed during the first week of life.

Infants in the highest quartile for cord blood DHA had higher retinal sensitivity compared with infants in the lowest quartile.

Dunstan et al (2007)32 Australia

DB PC RCT (n=98) pregnant women received 2.2g DHA, 1.1g EPA or olive oil from 20 weeks gestation until delivery.

DHA in breast milk correlated positively with Griffithâ&#x20AC;&#x2122;s developmental scores including hand and eye coordination.

Birch et al (2010)33 US

DB RCT (n=343). Term formula-fed infants received one of four infant formulas containing different amounts of DHA.

Infants fed the control formula (no DHA) had significantly poorer visual acuity (p<0.001). DHA supplied at 0.32% total fatty acids improved visual acuity.

Key: DB, double-blind; DHA, docosahexaenoic acid; PC, Placebo Controlled; RCT, randomised controlled trial.

the third trimester significantly improved infantsâ&#x20AC;&#x2122; performance of problem-solving tasks at nine months of age.25 Equally, Helland et al found that children born to mothers taking cod liver oil from 18 weeks into their pregnancies had higher mental processing and IQ scores.26 Two studies found limited effects of DHA supplementation, possibly due to low study compliance.27,28 Supplement compliance data from a subset of the DHA for Maternal and Infant Outcomes (DOMInO) trial28 showed that this was 47.5% at follow-up, indicating that this could have contributed to the shortfall in findings. Eye development

Five RCTs identified through PubMed looked at the effects of DHA on visual/eye development (Table 4). All studies reported benefits, although differing timescales and doses were used. Three studies found that DHA taken from midpregnancy until delivery helped to improve hand and eye co-ordination,29 infant visual acuity30 and retinal sensitivity.31 Dunstan and colleagues32 found that infant DHA status at one year of age was related 20

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to maternal DHA levels during pregnancy and six months after birth, but not antenatal supplementation, indicating the importance of continuing this after birth. Birch and authors33 focused on the composition of infant formulas, finding that DHA supplied at a level of 0.32% of total fatty acids was most effective at supporting visual acuity. Discussion

There is a growing body of evidence supporting the importance of DHA in pregnancy. Unfortunately, habitual intakes are substantially lower than European targets set at 250mg per day EPA+DHA for adults, with an additional 100200mg per day preformed DHA recommended during pregnancy and lactation.7 Further to this, the area in which a women lives and her level of education can also affect how much DHA is consumed from dietary sources,15,16 while other lifestyle factors, such as alcohol intake, have also been found to reduce maternal DHA plasma concentrations.34 While educational interventions have shown some improvements in pregnancy fish and DHA consumption, mean intakes still fall short of

PREGNANCY & NUTRITION

Given that the mother is the main provider of a child’s DHA when in utero and breastfeeding, it is important for health professionals to be aware of DHA pregnancy guidelines.

guidelines. For example, Oken and authors35 found that DHA intakes were just 70mg per day in the fish advice group and 161mg/day in the advice and grocery store gift card group who used these to buy fish with a low mercury content. Expectant mothers were guided about which fish to buy, using a booklet which listed fish according to their DHA content. Subsequently, alternative approaches are needed, with supplementation programmes being one way forward. Interestingly, findings from the APrON study showed that pregnant and breastfeeding women taking a supplement were 10.6 and 11.1 times more likely to meet European Union DHA recommendations.13 Other work has shown that supplementation with 200mg DHA from mid-pregnancy also helped to maintain the mother’s DHA levels both later in pregnancy (at 37 weeks gestation) and three months after birth.36 Equally, research by Sherry and colleagues (2015)37 found that 200mg or 400mg DHA taken four to six weeks after birth improved maternal breast milk and infant plasma DHA levels which are needed for brain development. Given that the mother is the main provider of a child’s DHA when in utero and breastfeeding,38 it is important for health professionals to be aware of DHA pregnancy guidelines. These can be communicated to women of childbearing age, along with suitable strategies to achieve these. Interestingly, findings from a study of 118 pregnant women showed that only 34% had received information about DHA, yet 68% said that they would like to know more.39 This paper has shown that the role of DHA in supporting the offspring’s brain and eye development looks promising, particularly when taken in the third trimester and after birth. Other work also points towards DHA having a role in improving motor (movement)

development,40 infant sleeping patterns,41 body composition and insulin sensitivity levels.42 There is also emerging evidence that low omega-3 levels in late pregnancy could be a risk factor for postpartum depression.43 Further studies now need to integrate the use of biological biomarkers to assess DHA status alongside dietary assessment tools. It is also important that future studies record supplement compliance, ideally following Consolidated Standards of Reporting Trials44 guidelines to do this, as this could affect DHA status and conclusions drawn from studies. Conclusions

DHA is an essential fatty acid with increasingly important roles during pregnancy and lactation. While DHA can be obtained from dietary sources, low bioavailability, high n-6 intakes from Western diets and concerns about oily fish consumption during pregnancy can all act as potential barriers to getting the proportions needed during this important life phase. Considering this, topping up habitual intakes with a supplement containing DHA seems to be the most effective approach in terms of safely achieving European recommended levels of intake. Health professionals can play a key role in communicating this information to women during pregnancy and lactation, especially those with lower education and income levels who are most at risk of shortfalls in DHA. Acknowledgements This review was funded by the Merck Group (Merck Selbstmedikation GmbH). The views expressed are those of the author alone and Merck Group had no role in writing the review. For article references please email: info@networkhealthgroup.co.uk NHDmag.com February 2016 - Issue 111

For the dietary management of mild to moderate cowsâ&#x20AC;&#x2122; milk allergy

Making life taste good! with improved

â&#x20AC;¢ Enhanced level of calcium which is needed for normal growth and development of bone1 â&#x20AC;¢ &RQWDLQV ODFWRVH ZKLFK VLJQLÄ&#x2020;FDQWO\ increases the absorption of calcium and improves palatability2,3 â&#x20AC;¢ +\SRDOOHUJHQLF IRU EHWWHU WROHUDQFH the most extensively hydrolysed formula in the UK4 â&#x20AC;¢ H[WHQVLYHO\ K\GURO\VHG ZKH\ SURWHLQ VRXUFH facilitates faster gastric emptying5,6 and provides a more palatable option7,8 FRPSDUHG WR FDVHLQ EDVHG H+)3,4

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PAEDIATRIC NUTRITION

Infant milk intolerance and allergy: are you sure?

Emma Coates RD Dr Schar, Mevalia Low Protein Dietitian

Emma has been a Dietitian for almost 10 years, working within the NHS in both adult and paediatric care for eight years. She is now Metabolic Dietitian at Dr Schar UK.

Milk allergy, milk intolerance, cows’ milk intolerance, cows’ milk protein allergy, food allergy, food insensitivity, food hypersensitivity, IgE mediated or non IgE mediated, adverse food reaction, non-allergic hypersensitivity… Is it any wonder that many parents and some healthcare professionals are baffled by the world of allergy and intolerance? There are many terms to describe the reactions to food, but which ones are correct? Allergy and intolerances are commonly seen as part of the caseload of most paediatric dietitians. With the diagnosis and management of an intolerance in comparison to an allergy being quite different, knowing exactly what you are working with is not always clear cut. Just to clarify, the overall term for food allergy and intolerance is ‘Food Hypersensitivity’.1 ‘Adverse food reaction’ is also used as the term to describe these reactions. Any reaction to food which is demonstrated with immunological symptoms is defined as an ‘immune mediated’ reaction and is sometimes described as a ‘food allergy’. ‘Immune mediated food allergy’ is also used. However, technically, coeliac disease is also included under this umbrella as it’s a non IgE mediated reaction. But many consider it not to be an allergy. Immune mediated reactions can be further subdivided in to three categories: 1. IgE mediated - for example in cows’ milk allergy; causing immediate onset symptoms* such as vomiting, abdominal pain, diarrhoea and/ or bloody stools, atopic symptoms such as wheezing and/or coughing, urticarial rash/hives, angioedema, blocked or runny nose. In severe cases anaphylaxis. Oral allergy syndrome (pollen associated food allergy syndrome) can also present as a consequence of IgE mediated activity. 2. Non-IgE mediated - for example in cows’ milk allergy; causing later

onset of symptoms** such as abdominal pain and distention, diarrhoea, constipation, colic, nappy rash, worsening eczema. 3. Mixed IgE and non-IgE mediated for example in allergic eosinophilic oesophagitis where chronic abdominal pain, vomiting and swallowing difficulties develop. Eczema is also a consequence of this type of reaction. * Within 30 minutes of consumption ** May take two to four hours for symptoms to present. Can been quite delayed and present after eight hours.

Any food reaction where there is no immunological involvement, the term ‘non immune mediated’ reaction should be used. This brings us on to the term ‘intolerance’; for example, both lactose intolerance and fructose intolerance are enzymatic non-immune mediated reactions. There are also pharmacological non-immune mediated reactions where histamine, sometimes found in fish or tyramine, found in ripe cheese, beers and red wine, are responsible for symptoms. Who really has an allergy or intolerance?

Immune mediated food allergy is quite rare, affecting approximately up to 8% of children in the UK,2,3 with cows’ milk allergy affecting 3-6% of infants and children.2 In 2014 the EAACI (European Academy of Allergy & Clinical Immunology) Food Allergy and Anaphylaxis Guidelines Group conducted a systematic review and NHDmag.com February 2016 - Issue 111

PAEDIATRIC NUTRITION Table 1: An overview of milk allergy and lactose intolerance Condition Key points Milk allergy - an immune mediated reaction to the proteins within mammalian milks, e.g. cows’, goats’ and sheep

Cows’ milk protein allergy Cows’ milk allergy

Commonly seen in infants less than six months of age. Can be IgE or non IgE mediated. Immediate or delayed reactions can occur. If IgE mediated - diagnosis via blood tests and skin prick tests to indicated presence of IgE. Good clinical history taking to determine non IgE mediated or intolerance diagnosis. Treat with extensively hydrolysed or amino acid infant formulas. Exclusion of milk and products containing milk.

Lactose intolerance - an intolerance to lactose, the sugar within mammalian milks. Caused by lactase deficiency and there is no immune mediated activity involved.

Primary lactose intolerance

Widely linked to ethnicity. Most commonly seen in children over three years of age. Late onset or delayed reactions tend to occur. Severity of symptoms can vary greatly. Caused by a gradual reduction in lactase as the child grows. Diagnosis via hydrogen breath test or stool testing for reducing substances or pH.* Exclusion or reduction of lactose within the diet. Often some lactose is tolerated depending on the individual. *Can be difficult to complete and services to complete the tests may not always be available. Also used in the diagnosis of other forms of lactose intolerance. Some questionability regarding accuracy when used invery young babies.

Developmental lactase deficiency

Presents in young infants, particularly premature babies.** Late onset symptoms tend to occur, in particular, colic like symptoms and/or diarrhoea. Lactase drops and/or a trial of a lactose free formula may be beneficial in its management. **Caused by lactase deficiency until at least 34 weeks gestation. Lactase activity mostly develops in the final trimester of pregnancy 8

Congenital lactase deficiency (Primary alactasia)

Very rare form of lactose intolerance. A hereditary condition (autosomal recessive gene). Caused by an almost complete absence of lactase. Presents at birth when first milks feeds are given. Characterised by watery diarrhoea and faltering growth. Lactose-free formula to be given. Breastfeeding is contraindicated. Strict lifelong lactose-free diet is required.

Secondary lactose intolerance

Acute lactase deficiency

Caused by damage to the intestinal villi where lactase activity takes place. Often as a result of gastrointestinal infection, e.g. rotorvirus. Common symptoms include diarrhoea, abdominal pain, bloating if milk is regarded into the diet. Treatment via a lactose-free formula and/or lactose-free diet for six to 12 weeks. Gradually reintroduce lactose into the diet thereafter.

Chronic lactase deficiency (CLD)

If regrading milk back in to the diet after a six- to 12-week exclusion is unsuccessful, CLD may be caused by an underlying condition. Cows’ milk allergy, inflammatory bowel disease, coeliac disease and the side effects of chemotherapy treatment are possible causes. Loose, watery, bloody or mucousy stools, abdominal pain/discomfort, faltering growth, food refusal plus any of the atopic symptoms may occur. Further exclusion of milk and products containing milk is recommended.

meta-analysis of the prevalence of common food allergies in Europe,4 It found that overall between 1-6% of common lifetime* food allergies were self-reported. In milk allergy, up to 3% of

lifetime cases were ‘food challenged defined’ with around 6% of cases being self-reported. *defined as ‘the proportion of the population that at some point in their life will have experienced food allergy’.5 NHDmag.com February 2016 - Issue 111

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PAEDIATRIC NUTRITION Table 2: YouGov report ‘Understanding the free-from market’ findings, 2015: health related reasons why parents are reducing diary in their children’s diet It’s healthier/better for you

27%

It’ll help with weight loss

11%

They have tried a reduction and feel better as a result

10%

They feel less tired if it is reduced

An intolerance is suspected

22%

It helps my child’s mood

14%

It was recommended by a friend/member of the family

11%

It was recommended by a healthcare professional

The statistics for non-immune mediated reactions show a variable prevalence depending on ethnicity. Up to 70% of the global population suffer from primary lactose intolerance.6,7 However, Allergy UK states that ‘perhaps one in five people will suffer symptoms suggestive of lactose intolerance’.2 Primary lactose intolerance is less common in Europeans, with approximately 2% of people affected, but incidence amongst people of American Indian and Asian origin may be as high as almost 100%.6 A matter of choice?

There is evidence to suggest that the prevalence of allergies and intolerances is increasing. Prevalence is not only increasing within the European population, but in countries where there is much industrial development occurring. In Europe, cases of food allergies have doubled over the last decade, with hospital admissions, because of severe allergic reactions, increasing seven fold.2 There is also evidence to suggest that a growing number of people are choosing dairy free as a ‘healthier option’. A recent report by YouGov9 reviewed the potential for the free-from foods market in the UK. It was found that nearly one in five people in the UK consider themselves to have a food allergy or intolerance (12% food intolerance, 6% food allergy, 1% coeliac disease). Up to a quarter of UK households includes at least one allergy or intolerance sufferer. In August 2015, 1,328 adult participants completed the YouGov online survey, which included 20 questions covering a variety of aspects relating to free-from diets and products. The survey also

looked at reasons for reducing dairy in the diet. Of the overall participants, 13% were actively trying to reduce their intake of dairy; however, 69% of these participants did not have a dairy intolerance or allergy. 15% of parents included in the survey were actively reducing the amount of dairy they give to their children. Of this, 6% of participants with children were reducing dairy in their diet due to an actual dairy allergy or intolerance. There were numerous reasons why parents were aiming to reduce the amount of dairy in their children’s diet. These are summarised in Table 2. The most commonly bought free-from products were milk, cheese and yoghurt. The report found that there is a great potential for the free-from market to grow in the UK. 39% of parents in the survey were buying specially designed free-from foods for their children. This was an increase from 28% in the previous year. 31% of parents were sending their children to school with a packed lunch due to a reported allergy or intolerance. As healthcare professionals, we are responsible for ensuring appropriate information regarding the indications for and the management of reducing or excluding dairy from the diet, is provided to parents who come to clinic. Yet, it seems that we may only be reaching the tip of the iceberg. The low rate of healthcare professional guidance for the general population, which is indicated in the YouGov report, is quite alarming: only 1% of participants received the recommendation to reduce or exclude dairy from their child’s diet via a healthcare professional. As I mentioned at the start of this article, knowing the difference between allergy and intolerance along with all of their intricacies is a challenge for many parents (and some healthcare professionals), which is a concern, as there are many parents choosing to reduce or exclude dairy from their child’s diet based on ‘suspected intolerance’. Unnecessary reduction or exclusion of dairy foods from the diet during childhood can be detrimental to the child’s bone health and development and, although there are dairy free alternatives available which are being purchased, we cannot be certain that consumption of these are adequate to meet a child’s daily requirements for calcium. For article references please email: info@networkhealthgroup.co.uk NHDmag.com February 2016 - Issue 111

FOLIC ACID

Fortification policy . . . Still waiting

Ursula Arens Writer; Nutrition & Dietetics

For article information sources please email info@network healthgroup.co.uk

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

The quality of the evidence of folic acid as the best method of risk reduction of NTD development is excellent and has never been seriously challenged, but the translation into a fortification policy has stalled. In the light of a proposed Scottish initiative to add folic acid to flour, Ursula Arens makes the point that evidence is not enough; politics, public opinion and power games all contribute to decisions on nutrition policy. Dietitians and doctors are now taught that you should evidence-base your professional advice. Was there ever another way? But what is meant by the shorthand phrase is that you should consider the tiers and quality of data available and from this, base the firmness and enthusiasm of your guidance to patients. If there is stronger evidence: shout. If there is weaker evidence: mumble. And if there is no good evidence: say so. Always easier said than done, and especially as in today’s informationoverloaded environments, there is often high quality data supporting seemingly opposite conclusions. A less considered aspect of evidence-based-medicine (EBM) is not the making of judgments and giving advice where evidence is weak, but rather the not making of judgments and not giving advice where evidence is strong. And the latter sadly captures the meandering trail of policy in the UK in relation to the subject of the fortification of foods with folic acid. So, it is wonderful that in October 2015, the UK’s top nutrition experts, members of the Scientific Advisory Committee on Nutrition (SACN), have written to the Health Ministers in England, Scotland, Wales and Northern Ireland, saying, paraphrased, “why are we waiting?”…because it is coming up to the 25-year anniversary of the publication of the results of the UK Medical Research Council (MRC) randomised double blind study, showing that additional folic acid

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in early pregnancy* reduced the risk of congenital neural tube defects (NTD) by more than 70%. There have been previous features on folic acid fortification practices in NHD Magazine (Arens, 2005, 2007) and I have my own reasons for particular interest in the subject, having had the great privilege of discussing the subject with Professor Sir Nickolas Wald, who is the UK’s most dedicated folic-acid champion. Nick Wald developed blood tests to identify spina bifida during pregnancy in 1974 and then led the Medical Research Council folic acid supplement trial 1983-1990 (MRC, 1991). Because the protective actions of folic acid occur so early in pregnancy and because of the much-quoted guess that about 50% of pregnancies in the UK are unplanned and unexpected, the fortification of foods was immediately under consideration as the best way to enhance the population status of mothers-to-be. In 1993 we discussed the possible effects that changes to food labelling regulations might have, to intakes of folic acid from fortified foods. The outgoing rules (UK Food Labelling Regulations of 1984) required for a labelling claim on a folic acid fortified food, at least one sixth of the reference amount, of 300ug, per serving. The incoming rules (EC directive on nutrition labelling of foodstuffs of 1990) required at least 15% of the reference amount of 200ug per 100g of food. As voluntary fortification decisions are

FOLIC ACID

. . . 83 countries have now introduced mandatory statutory fortification of foods . . . including most notably the USA . . . very strongly driven by labelling regulations, the changes could be predicted to strongly reduce actual intakes of folic acid from fortified foods. For example, intakes from a serving of breakfast cereal, where a serving size was 30g, would need to contain at least 50ug of folic acid under UK 84 regulations, versus only a measly 9.0ug of folic acid under EC 90 regulations. This was an unintended outcome of changes to the provision of nutrition information to consumers, but was likely to result in a dilution of folic acid fortification practices. The rather low hurdles needed to allow micronutrient claims on some foods (those whose portion size was much lower than 100g), has since been described as â&#x20AC;&#x2DC;pixiedustâ&#x20AC;&#x2122; dosing. Nick Wald was concerned over any developments that would reduce possible intakes of folic acid in the national diet, and was hugely keen to reach beyond academe, to involve food industry advisers in discussions on folic acid policies. A UK report from the Expert Advisory Group published by the Department of Health in 1992 recommended some modest support for voluntary fortification: this should be restricted to the food categories of breads and breakfast cereals, at levels not exceeding those in current (1992) products. Fortified foods should be labelled to indicate this, and there should continue to be a choice of unfortified breads and cereals available: in practice this was likely to be products that were wholemeal or organic. In the meantime, 83 countries have now introduced mandatory statutory fortification of foods (A-Y: Argentina to Yemen), including most notably the USA, with data demonstrating subsequent significant reductions in the incidence of NTDs in their populations. SACN have now (October 2015) written to Health Ministers requesting a decision be made

on measures to improve the folate status of the population. They had already presented risk assessments for a fortification policy in 2006 and 2009, and in both reports recommended the mandatory fortification of flour as a national policy. They reassured Ministers that no adverse effects on cardiovascular disease or on any site specific cancers had been observed from meta-analysis of data assessing the effects of increased intakes of folic acid. They cited calculations from the USA that the prevalence of NTDs had fallen from 10.8 to 6.5 per 10,000 live births, with an estimated healthcare cost saving US$508 million. Data on the number of NTD affected pregnancies in the UK suggested a possible increase. The recent UK survey of blood folate levels from more than 750 women (NDNS, 2015), showed levels lower than levels measured in US women prior to their national fortification policy, with 85% of UK women having levels below the targets set by the World Health Organisation for women of reproductive age. The final note of concern communicated by SACN to Health Ministers was that there had been a reduction in voluntary folic acid fortification of foods in the UK in recent years, in compliance with SACN recommendations prior to the instruments of mandatory fortification. This outcome was not intended or foreseen, but may have unintentionally reduced folic acid intakes in the UK population since 2006. So, with all the talk of decisions based on quality evidence, the work of Professor Sir Nicholas Wald, whose gold-level research was published in 1991, still sits on the pending pile. Hopefully, the SACN letter to Health Ministers will prompt some action, so that the UK population can finally benefit from enhanced folate status. And dietitians will be the essential profession needed to support and communicate the policy when it is announced - hopefully soon.

* Early pregnancy actually means very early pregnancy: the neural tube closure of the foetus occurs before about day 30 post conception, which is about two weeks after a missed period. Enhanced levels of folate status after this time will make no difference to the risk of NTD. So, in fact, only folic acid supplementation taken prior to conception, or immediately upon a missed period (usually prior to a positive pregnancy confirmation) can be protective. This does not fully match the impression conveyed by the advice to take folic acid supplements in the first trimester of pregnancy.

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CRITICAL CARE

Feeding critically ill obese patients Despite ongoing nutritional research in this area, there is a paucity of high quality research to guide the feeding of obese patients on the Intensive Care Unit (ICU). In a nutritionally complex population, this paper will review the available evidence and summarise key points to consider when assessing the nutritional requirements in the critical ill obese. Kaylee Allan BSc (Hons) Dietetics, PgCert Applied Sports Nutrition Specialist Dietitian, North Bristol NHS Trust

Acknowledgements: Many thanks to my colleagues Robert Cronin and Stephen Taylor for their help and support with reviewing this article. Thanks also to David Frankenfield for allowing adaptations to his previous work.

For article references please email: info@network healthgroup.co.uk Since graduating, Kaylee has spent over four years specialising within intensive care and adult burns. She is also part of a small research team on the ICU.

Obesity remains on the increase; in England, 61.9% of the adult population are overweight or obese.1 The cost to the health service for overweight and obese patients is greater than £6 Billion a year1,2 and contributes to 30,000 excess deaths in the UK.3 The ICU ‘obesity paradox’ has been used to describe this observed phenomenon of improved survival of the obese patients, despite increased lengths of stay,4 the opposite to what many might expect. Audits4 and multicentre observational studies5 evaluating the outcome of obesity in critical illness, found that patients with a BMI of between 30-39 and >40 had a lower mortality when compared to a normal BMI (<25). Theories try to explain why the obesity paradox exists, one suggestion is altered metabolism of the adipose tissue, an increase in Leptin levels and beneficial functions of adipose tissue in response to sepsis.5,4 Despite a large sample size of the studies, the morbidly obese patients (BMI >40) represented only 3.5% of the study population.4 A recent systematic review has also cast doubt over the existence of this paradox.6 Even if the ICU obese paradox exists, complexities arise with the medical and nutritional management of the obese critically ill patients that impact on morbidity. There is a strong link between obesity and insulin resistance and a prevalence of fatty liver and respiratory compromise. The risk of hypothalamic and pituitary

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dysfunction can result in increasing levels of the stress hormone cortisol. Poor mobility due to the critical illness heightens patient risk of pulmonary embolisms or deep vein thrombosis due to the patient’s hyper-coagulable state. 2, 7 Locally, over the last year, our ICU admitted 1,775 patients; of these, nearly a quarter (23%) were obese (BMI >30) and 4.0% morbidly obese (BMI >40).There is a need to have a consensus amongst our profession to ensure that the nutritional management of the obese patient is appropriate and evidenced based. Establishing a definitive nutritional pathway for obese patients on ICU remains an ongoing issue for dietitians due to complexities with assessing the nutritional need of the patient, alongside prescribing feeding regimens with adequate macro and micronutrients.8 Nutritional Requirements

Without the use of indirect calorimetry, predictive equations must be used when assessing nutritional needs of a patient.9 Predictive equations can be inaccurate and lead to over or under estimations of calorie and protein needs.9 The Parenteral and Enteral Nutrition Group (PENG)10 recommends calculating estimated energy requirements (EER) based on disease-related stress for BMI >30, protein/g/kg/d is adjusted to 75% and 65% requirements for obesity and morbid obesity respectively (Table 1). The supporting evidence behind this recommendation is somewhat sparse.

CRITICAL CARE Figure 1: Graph to show the bias in predictive equations in morbidly obese patients

source: adapted from frankenfield 2013 et al with permission.9 IbW: ideal body weight, mAT: metabolically active tissue. Penn state: (equation 1, for all patients irrespective of age).

Frankenfield et al9 evaluated the available predictive equations for 55 mechanically ventilated obese patients with a BMI >45. Predictive equations were compared to measured energy expenditure (MEE) to determine accuracy (Figure 1). The equation with the highest accuracy (±5.0% of measured EE) was the Penn State equation (2011); however, this was accurate in only 51% of the patients, so caution should be taken when using this equation in those with a BMI >45. The IretonJones equation (1992), which was developed specifically to include obese hospitalised patients, had an accuracy of 16% (to ±5.0% of MEE) and fixed kcal equations (25kcal/kg) has an accuracy of 0% to +/-10% if MEE.9 See Figure 1 for the predictive equations. Those recommended are highly inaccurate.9 Choban et al (2013) recommend the Penn State University equation (2009) should be used and the adjusted Penn State calculation used in patients over 60 years old. Recommendations for hypocaloric, high protein feeding suggest using 50-70% estimated energy requirements or 14kcals/ kg actual weight. Protein ranges are increased in the obese group (BMI >30), but supported with low grade evidence, see Table 1.11 Current guidelines offer suggestion to dietitians when calculating nutritional requirements in obese patients.

ASPEN’s D grade recommendations for feeding the obese ICU patients accounts for underfeeding calories, but feeding high protein allows for neutral nitrogen balance and wound healing.11, 12 Calculating protein requirements is just as problematic as estimating calorie requirements in the obese ICU patient. Table 1 gives a variety of protein ranges based on actual or ideal body weight. Obese patients have an increased level of total body fat as well as an increase of lean body mass (LBM) and IBW does not correlate to this change in body habitus. Accurately obtaining LBM is costly and often not feasible at the bedside, so using an equation to calculate LBM has been recommended.15, 16 Hypocaloric vs permissive underfeeding

Where indirect calorimetry and predictive equations accounting for obesity are not available, then clinical guidelines may assist and direct nutritional prescriptions in ICU obese patients. As Table 1 presents, giving a percentage or lower amount of calories to the obese patient (hypocaloric feeding) may be helpful in preventing negative side effects of overfeeding ICU patients, such as hyperglycaemia.7 Determining how much to feed the ICU obese patient will vary depending on clinical condition and individual aim. Within the literature, terminology varies and it is important to distinguish the significant difference of the two NHDmag.com February 2016 - Issue 111

CRITICAL CARE Table 1: Current nutritional recommendations Guidance

American Society for Parenteral and Enteral Nutrition ASPEN11,12,13

Energy

Protein

BMI >30-50 60-70% energy requirements or 11-14kcal/kg/actual body weight or

BMI >30-40 >2.0g/kg Ideal body weight

BMI >50: 22-25kcal/kg ideal body weight BMR - Henry (2005) or in ventilated patients use IretonJones equation (2002)

Parenteral and Enteral Nutrition Group (PENG)10

BMI>30 Not stressed: subtract 400-1000kcals. Mildly stressed: feed to BMR (calculated using actual body weight) Moderate stress: feed to BMI +/_ activity or stress factor

BMI > 40 >2.5g/kg ideal body weight BMI >30 75% protein requirement BMI >50 65% protein requirement

Severely stressed: add a stress factor OR use 19-21kcal/kg actual body weight American College of Chest Physicians (ACCP)14 Kreymann et al 2015

21-25kcal/kg/actual body weight

Do not give recommendations for protein requirements

Use Standard Body weight (SBW - adapted from Lemmens et al, based on BMI 22) x 25kcal 25kg x kg SBW

Based on LBM (adapted from Fernandez) and decide on range of protein required depending on clinical picture

terms: hypocaloric and permissive underfeeding. Hypocaloric feeding suggests low calories (mainly as carbohydrate) whilst maintaining adequate protein. Permissive underfeeding is a conscious decision to underfeed calories alongside protein.7 Hypocaloric feeding (low calorie, less than predicted energy expenditure) with adequate protein provision >1.2g/kg/d Ideal Body Weight (IBW) aims to maintain lean body mass (LBM) whilst simultaneously losing fat mass. Underfeeding calories aims at avoiding the metabolic complications associated with overfeeding in ICU patients, such as hyperglycaemia, increased infections and increased ventilator days.7 A small retrospective study of 40 obese ICU patients receiving enteral nutrition were fed either <20kcals/kg adjusted body weight/d (hypocaloric feeding) or >20kcals/kg adjusted body weight/d (eucaloric feeding). The findings suggested that the hypocaloric group had shorter ICU stay (P <0.03) and reduced number of ventilator days (P <0.09). Both groups were fed equal amounts of protein (2.0g/kg/d IBW).17 There is a lack of quality randomised control 32

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trials reviewing nutritional prescriptions for this patient group. However, the American guidelines suggest that hypocaloric, high protein feeding is at least equivalent as permissive underfeeding, if not improved when adequate protein is provided.8 Hypocaloric, high protein feeding

Using the hypocaloric high protein feeding strategy to optimise outcomes in the critically ill obese can present practical complications for dietitians prescribing enteral feeding regimes. Using commercial available enteral feeds can be a challenge to meet both requirements for protein and obligatory glucose without overfeeding, especially when also factoring in the delivery of non-nutrient calories such as propofol or IV fluid solutions. Failure to meeting obligatory glucose levels can lead to gluconeogenesis and exacerbate further loss of muscle mass.8 Protein supplements alongside commercially available tube feeds with a lower non-protein energy:nitrogen ratio <1:80) can improve protein intake without overfeeding energy.8 Adjustment of feeding regimens goes beyond that of using a pure

CRITICAL CARE protein supplement. Careful adjustment in feed prescription is essential when accounting for the nonnutritional energy provided in the form of intravenous fluids, sedation preparations and renal replacement solutions. Failure to adjust will lead to excess energy from non-nutritional sources, or displacement and reduction of protein intake. The provision of a protein and carbohydrate mixed supplements can help close the protein gap while meeting obligatory glucose requirement. Micronutrient provision will also need to be considered when making adjustments for macronutrients.8 Summary

Despite a suggestion of lower mortality from critical illness, obese critically ill patients present a lot of nutritional challenges to dietitians working on the ICU. We lack definitive answers to guide prescriptions for the ICU obese patient, but emerging evidence suggests that the trend towards hypocaloric feeding alongside adequate protein and glucose provision improves outcomes and prevents substrate intolerance. Estimating energy requirements should include using evidenced based and validated predictive equations, mindful that the

accuracy of these equations falls as BMI increases >45.9 Consideration for non-nutrient energy sources, adequate micronutrient provision and the use of protein and carbohydrate supplements help bridge the protein gap to ensure this patient group are adequately fed to optimise outcomes. Key points

• Use indirect calorimetry or validated predictive equations for the ICU obese patients. • If predictive equations aren’t available, follow international guidelines ensuring adequate protein is provided. • Feeding regimens need to be adjusted to allow for non-nutritional energy from sedation preparations, intravenous fluids and renal replacement solutions. • Consider a protein supplement to improve the protein adequacy, without over-feeding. Commercially available feeds may not provide enough protein for patients with increased protein requirements. • Pre-admission nutritional status: consider micronutrient deficiencies and adjust depending on clinical conditions.

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COMMUNITY dietetics

Malnutrition in the elderly: identifying and signposting with the PaperWeight Armband Kirstine is part of a team that is pioneering the PaperWeight Armband a non-medical, non-intrusive tool that is helping health and social care professionals to identify people at risk of malnutrition and signpost them to information and advice. Kirstine Farrer Consultant Dietitian, Salford Royal NHS Foundation Trust

Kirstine specialises in intestinal failure on the national unit at Salford Royal. She has extensive clinical experience, specifically in the management of short bowel syndrome and home parenteral nutrition,

The idea stemmed from being part of a 12-month national pilot programme set up by the Malnutrition Taskforce. The vision was to demonstrate an integrated approach to dealing with malnutrition; aligning health and social care and the voluntary sector. Now, thanks to a partnership with Age UK Salford, the PaperWeight Armband is set to be rolled out across the country to help save lives and cut costs associated to treating the condition - with a simple strip of paper. There has never been a more urgent need for healthcare providers and commissioners to act and address the problem of malnutrition. Needless suffering, neglect and inconsistent standards of dignity are unacceptable. Malnutrition is a major cause and consequence of poor health and older people are particularly vulnerable. It is a condition that frequently goes undiagnosed and untreated, with one in 10 older people suffering from, or at risk of, malnutrition. This equates to around one million older people in the UK and more than one in three are malnourished, or at risk of malnourishment on admission to hospital. Not only is this intolerable from a health perspective for the quality of life in older people, malnutrition can lead to more hospital admissions and readmissions, longer hospital stays and greater healthcare needs, which means the cost of malnutrition can spiral out of control. Here in Salford, we have an unashamedly ambitious aim. We wish

to ensure that we work in collaboration with health and social care and the voluntary sector to remain committed to ensuring high standards of nutritional care and equal access across the city. The challenge was how to go about this and our journey with the PaperWeight Armband started in 2013, when Salford was chosen as one of six pilot sites to be part of a Malnutrition Prevention Programme for 12 months. We looked at current services, support and prevention tools available and gained views from members of the public and health and social care professionals through a nutrition committee set up by the integrated care programme â&#x20AC;&#x2DC;Salford Togetherâ&#x20AC;&#x2122;. It was concluded that we wanted to establish a non-intrusive, non-medical intervention solution that healthcare providers and the voluntary sector would be able to implement quickly and easily into their practice. The PaperWeight Armband was born out of this. Piloting the PaperWeight Armband

Age UK Salford supported the case for a simple signposting tool, as there was not one currently available to help carers, healthcare or social care professionals in broaching the subject of malnutrition. A public engagement exercise with older adults, who thought it was normal to lose weight in later life, also revealed that some did not want to be weighed. Age UK Salford went on to pilot the PaperWeight Armband with support NHDmag.com February 2016 - Issue 111

COMMUNITY dietetics workers using it on home visits. They were able to measure the upper arm of a service user with the simple strip of paper and, if it was able to slide up and down easily, then there was a high risk of malnutrition, as it was likely that their BMI was less the 20kg/m². The charity Age UK was then able to provide further information, advice and support and the results were really positive, with service users gaining weight, making improvements to their diet, and enjoying cooking and eating again. When the national Malnutrition Prevention Programme ended in March 2015, it was agreed by the nutrition committee that there was a strong commitment to continue this work to roll-out the PaperWeight Armband and Age UK Salford have partnered with us to make this happen. The PaperWeight Armband was launched at Food Matters Live 2015 and now, alongside this signposting tool, there is a supporting handbook, nutrition booklet and e-learning resources on malnutrition and dysphagia. Advice and guidance

The aim of the PaperWeight Armband package is to identify the risk of malnutrition and in turn help to reduce unscheduled admissions to the acute hospital of those identified with malnutrition in the population, make improvements in weight without the need for formal medical intervention, increase the proportion of older people who feel supported to manage their own conditions and improving the quality of life for service users and carers. This simple signposting tool that comes with a wealth of information, aligns a shared vision we have with Age UK, of a world in which older people flourish; a world in which older people have the opportunity to live healthier, longer lives and to enjoy a sense of wellbeing while maintaining choice and independence. The PaperWeight Armband is lightweight, can be easily stored and transported and complies with infection control guidelines for single use only, as well as being easily recycled. There is a QR code on the armband so that it can be scanned to directly access the dietary leaflet on the Age UK Salford website that has proven to be invaluable to Salford health and social care professionals seeking ‘food first’ approaches to dealing with the risk of malnutrition. The guidance outlined 36

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in the leaflet should be followed for a maximum of 12 weeks, following which time, if there is no improvement, the advice is to ask to see a healthcare professional. It can be used when scales and height charts are not available, when support workers are short on time with a whole day of scheduled visits or, if someone is reluctant to be measured, for example, a person with dementia. Case studies

Case study evidence has shown how well the PaperWeight Armband works as a signposting tool and how it leads to further support. One woman was able to get back on her feet after the early intervention of the armband. The 91-year-old who lives alone, spent a period of time in hospital and the day after she was discharged, she was called by Age UK Salford’s Hospital Discharge Aftercare and Reablement Service, who established that she was having difficulties with eating meals. During the initial home visit, discussions identified that she had lost a lot of weight and had no motivation to cook or eat well. The Age UK Salford support worker used the PaperWeight Armband test, which identified that she was at risk of malnutrition. She was provided with the nutrition booklet, ‘How to improve your food and drink intake if you have a poor appetite’ and over the following eight weeks, the support worker visited her to encourage her to increase her nutritional intake. At the end of the eightweek period, she had gained 4kg in weight, was making home cooked meals two or three times

COMMUNITY dietetics

The hope now is that the hard work that Salford has pioneered to help fight malnutrition will spearhead an integrated approach to dealing with it . . . a week and went out with her friend regularly, including a lunch group. The woman reported improved confidence; reduced attendance at her GP; more independence and a renewed interest in food and nutrition again. Another case study has also shown how well the PaperWeight Armband and supporting information works to help fight malnutrition. A 65-year-old man with learning difficulties had lost weight unintentionally, which was noticed by his carers. It was established that his housemates were on a weight-reducing regimen, therefore, the communal food in the fridge, such as milk, butter and cheese, had been changed to low-fat varieties and sugar had been replaced with an artificial sweetener. His carers sought advice from Age UK Salford and then used the PaperWeight Armband to establish that he was at risk, then simple changes were made with help from the nutrition booklet. This resulted in him gaining 7kg in weight over a 12-month period and he also started to enjoy his food again. These two examples not only show how quick and easy the PaperWeight Armband is to use, it also shows how effective it is as a non-medical, non-intrusive tool that is a starting point to help health- and social care professionals - as well as family carers - fight malnutrition. Joined-up care at Salford

As a vanguard site, Salford Royal NHS Foundation Trust is set to be at the forefront of a national health revolution that will bring home care, mental health and community nursing, hospital and outof-hospital services together, ushering in a new era of joined-up care. Together, we believe that prevention and treatment of malnutrition should be integral to ensure that older people can live more independent, fulfilling lives. The hope now is that the hard work that Salford has pioneered to help fight malnutrition will spearhead an integrated approach to dealing with it, helping to save lives and reducing costs

- all starting with a simple strip of paper. The armbands can be bought by healthcare providers in packs, along with the handbook, nutrition booklets and a poster that can be displayed in a workplace to show it is being used. For more information on the PaperWeight Armband and to view a short video on the background to the product development, go to the following link. www.ageuk.org.uk/salford where you can also register for more information and a starter pack. Top tips for service users to improve intake

(Taken from the PaperWeight Armband supporting booklet: How to improve your food and drink intake if you have a poor appetite) • Have small regular meals and snacks in between. • Try to eat something every two to three hours, even if it is only something small. • Have puddings or desserts at least once a day, if you are too full after a meal, wait 30 minutes. • Alcohol in small amounts can stimulate an appetite, but it is important to check with a doctor or chemist if taking any medication. • If you smoke, try not to smoke in the half hour before a meal. • Getting a small amount of fresh air before meals can help to stimulate an appetite. • Take drinks after meals rather than before or with to avoid feeling too full or bloated. • Make the most of ‘good days’ or times during the day when you feel more like eating. • Enriched nutritional drinks, for example, Complan and Build Up, are available to buy from chemists and supermarkets and are available in a wide-range of preparations, including flavoured drinks and soups. • If after four weeks of trying some of the suggestions to your diet, you are still concerned or losing weight, contact your GP practice. NHDmag.com February 2016 - Issue 111

LITTLE THINGS CAN MAKE A BIG DIFFERENCE FOR WINSTON, THAT’S PLAYING SOME CLASSIC JIMMY REED You can keep this a reality with Ensure Compact • Great taste1 • 99% compliance2 • Low volume, 125 ml (2.4 kcal/ml, 13 g protein)

REFERENCES 1. Data on File. Abbott Laboratories Ltd., 2013 (Ensure Compact Palatability Research). 2. Data on File. Abbott Laboratories Ltd., 2013 (Ensure Compact Compliance Research). Date of preparation: October 2015 RXANI150237a

FOOD ALLERGY

Food Allergy in Adults

Dr Isabel Skypala BSc PGDip (Allergy) PhD RD Consultant Allergy Dietitian, Royal Brompton & Harefield NHS Foundation Trust

Isabel has over 30 yearsâ&#x20AC;&#x2122; experience in food allergy. She is author of peer-reviewed papers and books, honorary Senior Clinical Lecturer at Imperial College and member of the executive committee of the European Academy of Allergy & Clinical Immunology.

Adverse non-toxic reactions to foods are typically classified as food allergy if the immune system is involved.1 An average of 15% of UK adults and 20% of Europeans report allergic reactions to foods.2,3 However, true food allergy is likely to affect less than 5.0% of the adult population.4,5 Food allergy is more likely to present in those who have other allergic conditions (rhinitis, eczema, asthma) and are sensitised (have specific IgE antibodies) to aeroallergens, such as pollens. However, the presence of specific IgE antibodies to foods is not a risk factor6, probably because adults are frequently sensitised to foods in the absence of any reported symptoms.3 Those referred to an adult food allergy clinic frequently suspect milk and/ or wheat to be causing or exacerbating their symptoms. However, milk, wheat, egg and soy allergy usually resolve in childhood and rarely present as a new allergy in adult life.7-10 The most probable cause of symptoms to milk in adults is some degree of lactose intolerance,11 although respiratory symptoms are also frequently reported by those with asthma or other lung conditions.12 Wheat is primarily associated with gastrointestinal symptoms,13 so coeliac disease should be excluded prior to considering other differential diagnoses such as functional gut disorders provoked by fermentable carbohydrates14 or noncoeliac gluten sensitivity.15 However, wheat does play a prominent role in a relatively rare IgEmediated food allergy; food-dependant exercise-induced anaphylaxis (FDEIA)16 is characterised by a lack of reaction

to the trigger food unless it is consumed in close proximity to taking strenuous exercise, although dancing, gardening and even walking have all been reported to trigger symptoms.17 In the absence of exercise, other co-factors such as aspirin, nonsteroidal anti-inflammatory drugs (NSAID) and alcohol can also enhance or precipitate an allergic reaction to food.17,18 Apart from wheat, other common trigger foods include shellfish, tomatoes, celery and nuts.19,20 Seafood

Seafood, fruits, nuts and vegetables are the foods most likely to provoke new-onset allergic symptoms in adults.2,3,6,21 Seafood allergy in adults usually involves shellfish rather than vertebrate fish, with crustaceans, especially prawns, most likely to provoke symptoms which are often severe.22-24 Although sensitisation to minor seafood allergens can occur, it is the muscle protein tropomyosin which is the primary pan allergen in both crustaceans and molluscs.25-27 Tropomyosin is water soluble and heat stable, so allergic symptoms can be triggered by inhalation of cooking vapours28 or by the residue of prawns in cooking oils.29 The low similarity or homology between the tropomyosin NHDmag.com February 2016 - Issue 111

food allergy

in molluscs and crustaceans means crustaceanallergic individuals are less likely to also react to molluscs.28 The pan allergen Î˛ parvalbumin is responsible for most allergy to fish; its abundance in cod and herring means that adults with fish allergy are more likely to react to these fish, rather than swordfish and tuna which have very low levels of Î˛ parvalbumin.3032 The lack of homology between tropomyosin and Î˛ parvalbumin usually enables shellfishallergic individuals to tolerate fish and vice versa.33 Scombroid poisoning, caused by an excessive level of histamine due to the bacterial decarboxylation of histidine, is a common differential diagnosis for seafood allergy.34 Pollen-Food Syndrome

Although seafood is a common provoking agent, cross-reactivity syndromes cause the majority of presenting symptoms in adults.35 Dominant amongst these is Pollen-Food Syndrome (PFS), also known as Oral Allergy Syndrome (OAS), an allergy caused by cross-reactions between pollens and plant foods.36,37 The cause of PFS symptoms is the homology or similarity between allergen sequences in pollens and the Pathogenisis-Related 10 (PR-10) proteins and profilin allergens found in plant foods.38 Over 60% of birch sensitised individuals are likely to develop PFS39 because the PR-10 proteins crossreact with Bet v 1, the dominant sensitising allergen in 90% of birch-pollen allergic subjects,40 although profilins in trees, grass, and weeds can also provoke symptoms by cross-reacting to those in plant foods.37 PR10 allergens and profilins are susceptible to heat and digestion, so, although the foods involved can cause immediate moderate to severe localised oropharyngeal symptoms when raw, reactions to 40

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cooked plant foods or systemic reactions such as anaphylaxis are unlikely, although high protein foods such as tree nuts and legumes have the potential to provoke more severe PFS reactions.41 In the UK, 2.0% of the adult population has PFS and the foods usually involved include tree nuts, apples, kiwifruit, strawberries, peaches, cherries, tomatoes, carrots, peanuts, melon and potato peel.2 Since only 8.0-10% of newly diagnosed peanut and tree nut allergy occurs in adolescence or adulthood, new onset symptoms to nuts are usually due to PFS.42,43 The use of molecular diagnostic methods can determine whether the individual is sensitised to the primary allergens in peanuts (Ara h 2), soy (Gly m 5/Gly m 6) and hazelnuts (Cor a 9 and Cor a 14), or whether it is the PFS-related Bet v 1 homologues in peanut (Ara h 8), soy (Gly m 4) and hazelnut (Cor a 1) that are predominant.44-46 Latex-fruit syndrome

A similar cross-reactivity syndrome is latexfruit syndrome, but instead of pollen, the primary sensitising agent is natural rubber latex (NRL) (Hevea brasilienisis). Individuals sensitised or allergic to NRL have reactions to plant foods containing homologous allergens.47 Characteristic foods involved are avocado pear, chestnut and banana, but a huge number of other plant foods have been reported to provoke symptoms, especially in individuals sensitised to the NRL profilin allergen Hev b 8.48,49 The other major cross-reactivity syndrome also involves homologous plant allergens; lipid transfer proteins (LTP) are prolamins which, in addition to being primary sensitising allergens, may also cross-react with other LTP allergens.50 LTP allergy is most prevalent in the Mediterranean region, typically manifesting as a primary allergy

food allergy

A similar cross-reactivity syndrome is latex-fruit syndrome . . . . Characteristic foods involved are avocado pear, chestnut and banana, but a huge number of other plant foods have been reported to provoke symptoms . . .

to peaches due to sensitisation to the peach LTP allergen Pru p 3, with some individuals experiencing symptoms to other plant foods due to cross-reactivity between Pru p 3 and other LTP allergens.51,52 Unlike PR10 and profilin allergens, LTP allergens are not susceptible to heat or gastric degradation and, therefore, both cooked and raw foods are involved. Reactions involving LTP allergens are particularly associated with presence of co-factors, especially alcohol and exercise.53 Although peach is the main trigger food in Italy and Spain; in the UK, those with LTP allergy most frequently report tree nuts, peanuts, stone fruit, apples and tomatoes to cause the most reactions.54 Multiple food reactions

If the reactions are to multiple foods and PFS is not suspected, then an added allergen, such as an ingredient in composite dishes, may be implicated.55 Potential food allergens include cereals such as barley and rice (which can be due to LTP allergy),56 buckwheat,57 legumes added to other products (soy, lupin, chick peas, pea protein, lentils, fenugreek and guar gum),58-62 seeds (mustard, sesame, pine nut)63,64 and seasonings, including celery,65 mustard,66 coriander, cumin, anise, paprika and spice mixes such as garam masala and curry powder which can also contain fenugreek. Natural food colourings, such as carmine (cochineal)67 and annatto68 may also be relevant. Reactions to multiple foods in the absence of IgEsensitisation might indicate sensitivity to benzoates, sulphites, mono-sodium glutamate, vasoactive/biogenic amines or salicylates, although there is little published robust evidence to demonstrate the prevalence of reactions to these substances.69

Diagnosis

With regards to diagnosis, skin prick testing is a useful first line test, using fresh fruits and vegetables if PFS is suspected. Specific IgE blood tests to individual foods are also useful, but due to the degree of poly-sensitisation to foods in those with pollen allergies, it is important not to test for foods which are tolerated and habitually eaten without symptoms. Skin prick or specific IgE testing to aeroallergens is, therefore, essential to address potentially confounding results due to cross-reactivity,1 and molecular allergy tests can be useful for the diagnosis of cross-reactive syndromes. It is important to undertake oral food challenges where tests are negative, giving increasing standard doses of the food suspected.70 An adult-sized standard serving of the food must be given at the end of a challenge, in order to ensure sufficient allergen has been consumed; for some foods such as prawns, the cumulative dose required to provoke an allergic reaction can be considerable.31 Avoidance of the major allergens affecting adults will not normally cause major nutritional deficiencies where only single foods are avoided, but adults avoiding multiple foods can be at nutritional risk.71 People with a chronic lung condition requiring regular doses of oral prednisolone, or those with severe or prolonged gastrointestinal symptoms, should have a full dietary assessment and blood screen to assess their level of vitamin D, calcium, vitamin B12, folate and iron studies, even if they are only avoiding one major food group.72 For article references please email: info@networkhealthgroup.co.uk NHDmag.com February 2016 - Issue 111

IMD WATCH: IN ASSOCIATION WITH THE NSPKU

Epilepsy and Ketogenic Diet Therapy: Managing expectations in patients

Kit Kaalund Hansen Adult Ketogenic Diet Therapy Dietitian, University College London Hospital

In the first of our new IMD columns from the NSPKU, Kit Kaalund Hansen looks at Ketogenic Diet Therapy as a dietary management for patients with epilepsy. Many assume that the ketogenic diet will fast track them to a seizure-free lifestyle and, whilst reducing seizure activity and improving overall quality of life are the ultimate goals of specialist therapy, the complexity of the diet and the gargantuan commitment is often, if not always, undermined.1 Ketogenic Diet Therapy (KDT) is considered a medical treatment and must be complied with every minute, of every day, on all occasions, in the same way that patients must keep taking their prescribed anti-epileptic medications.2 If you miss a dose and the equivalent in dietary terms, treatment is less likely to be successful. In most cases, taking a pill is much easier than weighing, measuring and recording every ounce of calorie you consume. So, how can we manage our patientsâ&#x20AC;&#x2122; expectations, so that they can make an informed decision as to whether KDT is suited to their lifestyle? Also, what is our responsibility as healthcare professionals to ensure the continued safety of the patient? Donâ&#x20AC;&#x2122;t hide the fact that KDT might not work for them

Kit has spent three years exploring the ever-changing specialist area of inborn errors of metabolism. In late 2015, she was fortunate to become the first NHS funded Ketogenic Dietitian for adults with epilepsy in the UK.

A review of multiple studies concluded that KDT may be successful for 50% of adults with epilepsy by reducing seizures and/or seizure duration and/or recovery time by 50%, hence improving quality of life.3 The hope is that KDT will improve memory, concentration and overall energy levels along with some seizure control. If KDT issuccessful, the changes will take effect relatively quickly.1 A threemonth trial is generally sufficient to indicate whether the impact on quality of life makes KDT worth pursuing longer term.

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WHO IS A KETOGENIC DIET THERAPY FOR?1 The Modified Ketogenic Diet is appropriate for those settled at home and able to feed themselves, cook, shop and make their own informed choices. Those living in a care home setting or requiring tube feeds as all or part of their nutrition, or have feeding difficulties, or a more intermittent appetite may be better with a more structured regime. Medical screening (neurologist or GP)4,5

Make the patient aware that they might not be suitable Some conditions might make a ketogenic trial unsuitable or even hazardous. It is also important that lipids, various vitamins, minerals and functional markers are checked at baseline before commencing a prescribed ketogenic regime. These are then checked again at three and 12 months to monitor any potential change. If the changes are deemed significant and a threat to the wellbeing of the patient, KDT must be stopped immediately and an appropriate weaning plan put in place. A considerable change to eating habits6

Assess food preferences and dislikes Ensure that the patient does not underestimate the commitment they are about to make. KDT commonly involves a significant shift in food choices and the

CONTRAINDICATIONS: • Inborn errors of the metabolism: Fatty acid oxidation defects, organic acidurias, pyruvate carboxylase deficiency, other disorders requiring a high carbohydrate treatment • Familial hyperlipidaemia • A history of renal stones • Pregnancy or planning a pregnancy CAUTION: • Dysphagia (swallowing problems) • Gastro-oesophageal reflux and a history of severe constipation need to be appropriately managed prior to initiation • Diabetic on medication

way meals look. As with any significant change in diet, it is more difficult to make the switch all in one go. Therefore, I tend to encourage ‘stepdown’ preparation for one to two weeks in advance. In this way, the patients have a chance to try out new recipe ideas and become familiar with the basic principles, weighing and measuring, specific dietary sources of fat and foods low in carbohydrates etc. The aim is to make the final changeover much easier to cope with. Cooking meals from scratch6

Always account for the patient’s abilities and limitations Are they safe to cook? Are they good with numbers? Are they committed? Ready-meals are rarely available and not many shop bought snacks are ‘keto-friendly’. Meals generally need to be prepared from fresh with raw ingredients and, therefore, a willingness to cook is essential. Planning ahead and food preparation is key. Patients need to be acceptant of the fact that keto-friendly meals cannot be shared with other members of their household, as this is a medical diet and suitable for them only.

Careful record keeping7

KDT is labour-intensive and often tedious Throughout the first three months of treatment, it is essential that patients record daily fat and carbohydrate exchanges, twice daily blood ketones and glucose, any seizure activity and weekly weights. You will find that the level of commitment becomes clear very quickly. Adaptation to likely frequent changes to your dietary regime7

Prepare for dietary changes along the way KDT is entirely individualised and the patient’s dietary prescription will need adjustment along the way. This adjustment depends on the individual’s records of seizures and associated symptoms, blood ketone/glucose levels and weight change. Support network8

Investigate the patient’s social circumstances Radically changing eating habits can be tough under any circumstances, but KDT is much more than this. The patient becomes responsible for delivering their own treatment, monitoring its effects and making it work with the supervision of a specialist dietitian. It is essential that the patient is ready to take responsibility for their actions as KDT can be empowering, overwhelming and worrying all at the same time. Moral and practical support from those around them is of great importance. For more information on the work of The National Society for Phenylketonuria (NSPKU) visit www.nspku.org/ For more information and support on Ketogoneic Diet Therapy: National Hospital for Neurology and Neurosurgery NHNN www.uclh.nhs.uk/OurServices/ OurHospitals/NHNN/Pages/Home.aspx Matthew’s Friends www.matthewsfriends.org/

References 1 Kossoff EH, Dorward JL The modified Atkins diet. Epilepsia. 2008, 49(Suppl 8) 37-41 2 Lefevre F, Aronson N. Ketogenic diet for the treatment of refractory epilepsy in children. A systematic review of efficacy. Pediatrics, 2000, 105 E46 1-7. 23 3 Levy R, Cooper P. Ketogenic diet for epilepsy. The Cochrane Library Issue 3. Chichester, UK: John Wiley, 2004 4 Delgado MR, Mills J, Sparagana S. Hypercholesterolemia associated with the ketogenic diet. Epilepsia, 1996, 37(Suppl 5) 108 5 Nizamuddin J, Turner Z, Rubenstein JE et al. Management and risk factors for dyslipidaemia with the ketogenic diet. J Child Neurol, 2008, 23 758-61 6 Greene AE, Todorova MT, Seyfield TN. Perspectives on metabolic management of epilepsy through dietary reduction of glucose and elevation of ketone bodies. J Neurochem, 2003, 86 529-37 7 Kossoff EH, Zupec-Kania BA, Vining EP et al. Optimal clinical management of children receiving the ketogenic diet: recommendations of the International Ketogenic Diet Study Group. Epilepsia, 2009, 50 304-17 8 Eltze C, Fitzsimmons GJ, Sewell M et al. Great Ormond Street Hospital: Clinical Guidelines for the Ketogenic Diet, 2010. www.gosh.nhs.uk/healthprofessionals/clinical-guidelines/the-ketogenic-diet-in-the-management-of-epilepsy. Accessed 31 October 2012.

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on behalf of peng

PENG: because support and influence matter In a new column from the Parenteral and Enteral Nutrition Group (PENG) of the British Dietetic Association (BDA), Chair, Anne Holdoway provides us with an overview of the plethora of projects undertaken by the PENG Committee, Clinical Leads and members in support of the dietetic profession. Anne Holdoway, BSc, RD, MBDA

Nutrition support is now a vast speciality with the potential to achieve a positive impact on outcomes in many settings. As many dietitians are involved in nutrition support, the Parenteral and Enteral Nutrition Group (PENG), a specialist group of the British Dietetic Association (BDA), was delighted to be invited to write a series of articles for NHD readers. Over the coming months, we will be informing NHD readers of new developments in the field of nutrition support, illustrating how, in today’s climate, PENG can help to promote safe, high-quality nutritional care and raise the profile of dietitians. Our focus on advancing practice

Anne is a Registered Dietitian and Freelance Dietitian, Chair Parenteral and Enteral Nutrition Group, Specialist Group of the British Dietetic Association, Council Member of BAPEN

Research and audit are crucial to develop our evidence-base and underpin practice. In 2014, PENG ran a survey to understand membership engagement in research and audit. The results identified the extent that PENG Members were involved, barriers to participating and support mechanisms needed to facilitate up-skilling and action. The results were used to shape our three-year research and audit strategy and project plans. Funding was identified as a key barrier to undertaking research and audit, we, therefore, agreed to ringfence some of PENG’s financial reserves to fund small-scale projects. We recently awarded our first grant to Melanie Baker, Senior Specialist Dietitian at Leicester Royal Infirmary to fund a retrospective audit on the ‘Management of High

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Output Stomas’. Key in advancing the science and practice of dietetics, we hope to grant more awards in 2016. The survey also identified a lack of confidence amongst members in publishing results. We therefore, focused the PENG study day in November 2015, on how to produce and publish work and utilise evidence to change practice and support business cases. In response to lack of confidence in getting started and publicising work, we have also established a buddying and mentor scheme. Going forward, we will be developing a research and audit area on the PENG website. Resources

Supporting dietitians in everyday practice, the PENG Pocket Guide to Clinical Nutrition (4th edition) continues to be hugely popular in providing evidence-based knowledge at the fingertips of thousands of dietitians. New sections on bariatrics, pancreatitis and COPD have been added through collaboration with colleagues in other Specialist Groups including BOMMS and the Pancreatic Society. Based on patient/carer surveys, we have also just released our first in a series of information leaflets to support decision-making amongst patients and carers. Written in conjunction with NNNG and PINNT and tested amongst patients, the resources are freely available to all via the PENG website: www. peng.org.uk/publications-resources/ resources-for-patients-hcps.php

on behalf of peng Whilst many departments have their own local tools for the management of malnutrition, the Managing Adult Malnutrition in the Community guide and pathway, continue to be valuable resources with 30,000 visitors to date. The website has recently been redesigned to ease navigation and content expanded with new clinical areas covered. The pathway and guide were also adapted and published in Medendium’s ‘Guidelines’ and ‘e-Guidelines’, which reach 33,000 GPs and with over 52,000 registered users, thus providing HCPs with easily accessible information on steps to take to screen, treat and prevent malnutrition. Education and training, events and bursaries

As for many Specialist Groups of the BDA, education and training is a key focus to help advance the profession and develop our skills. The recent study day in London on utilising data for the purpose of research and audit was a huge success as measured in the feedback and evaluation and as evident from the interactive workshops. As part of our commitment to ongoing education and the development of advancing dietetic skills in nutrition support, we continue to run the Clinical Update course annually. This unique course, now at Masters level, remains popular with up to 75 participants a year. In response to restrictions on training budgets, we have recognised that funding for courses is limited and in the last two years have funded 10 bursaries to assist dietitians in attending. Through the generous support of industry, we have also been able to continue to offer an annual PENG Award; each year this can be in a different guise according to membership needs. In 2015, six £250 grants were awarded to PENG Members on merit for audit and research that had been undertaken and submitted for presentation at our November study day. The grant covered travel and subsistence, enabling the winners to attend to showcase their work, disseminate results and empower others to emulate the studies in order to build national data to help evaluate our impact.

PENG communications

Our three-times-a-year electronic newsletter, e-PENlines, regular live updates via the PENG website and emails, keep our Members in touch and connected. In 2015, we started a ‘teaser’ version of the e-PENlines that non-PENGmembers can access. In 2015, the PENG website www.peng.org.uk was revamped too, adding content along with improvements to optimise navigation and mobile device access. There remains a specific Member’s section of the website, as well as open access to areas advertising courses, some resources and getting to know PENG as a Group. Web activity is monitored so that we can understand who visits what pages, usefulness of resources and what information dietitians are seeking. In any year, there are in excess of 13,000 visits. Recognising that feedback is important to help us refine support to Members and continue to evolve, we encourage Members to contact the Committee via PENG email directly and we regularly undertake surveys amongst Members. A monthly poll on our home page (one for enteral and one for parenteral) is an opportunity for us to obtain insights from HCPs working in nutritional support. We also seek to involve Members in projects and a recent increase in the response to calls of engagement, including calls for applications to posts with the Advisory Committee for Borderline substances (ACBS), NICE and the PENG outcomes project work, is extremely encouraging. NHDmag.com February 2016 - Issue 111

on behalf of peng

PENG acknowledges the importance of liaising with other Specialist Groups of the BDA to avoid duplication of efforts. On a social media platform, PENG has a dedicated Twitter feed - any news item shared or added is immediately tweeted. Non-Members can sign-up and in 2016, the Twitter account will be more interactive. National influence, ambassador roles and collaboration

PENG has been privileged to represent the profession in developing a range of key national documents, including the NHS England ‘Commissioning Excellent Nutrition and Hydration’ (www.england.nhs.uk/ commissioning/nut-hyd/) and the ‘Com-plex Nutritional Care standards’ in Scotland (www. healthcareimprovementscotland.org/our_work/ patient_safety/improving_nutritional_care/ complex_nutrition_standards.aspx). We have actively participated in key stakeholder meetings at a national level with government ministers, Age UK, BSG, RCGPs, DH, Carers UK and the Faculty of Public Health. Along with published articles, we have strived to raise the profile and value of dietitians and the importance of good nutritional care. Whilst presence at our own BDA Conference is important, we also recognise that presentations to others is crucial to get key messages across on the importance of timely nutritional care. In the past year, PENG has presented at AGE UK, BAPEN, the Digestive Diseases Federation meeting, Primary Care and Public Health and ESPEN.

Multi-professional working and core functions within BAPEN

Back in the 90s, Members of PENG, together with patients, gastroenterologists, clinical nutritionists, biochemists, pharmacists and nurses, with a shared ambition to make nutrition an integral part of care, came together and formed ‘BAPEN’. PENG has remained a ‘core’ and founding Group and it is true to say that BAPEN could not achieve what it does without the valuable input from its dietetic Members. As 46

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a core Group, PENG has access to a significant clinical network and with an active dietetic Member on every BAPEN Committee (Quality, Education and Training, BANs, Programmes, BIFA) and a position on BAPEN Council, PENG is able to influence policies and campaigns to raise the profile of nutrition and the role of the dietitian. Recognising the importance of the patient voice and placing patients and carers at the heart of decision-making, the PENG Committee is also in regular contact with PINNT. Work within BAPEN is a prime example of multi-professional working. Whilst much engagement takes place within the Committees and electronically, the PENG Committee and Clinical Leads participate and lead on numerous BAPEN initiatives to achieve measurable and practical outputs. In the past year, we have been involved in the development of the BAPEN selfscreening tool (www.malnutritionselfscreening. org) and dietitians from within and outwith PENG, played a key role in developing and testing the new BAPEN Nutritional Care tool. To be successful, this new tool will be very much dependent on dietitians participating in data collection. Data collection has been kept simple and collation and analysis are automatic. As a national portal, return on investment is considerable as the tool has the capacity to provide valuable insights into the treatment and prevention of malnutrition locally and nationally and builds on the data from the former BAPEN nutrition screening weeks. Please do consider signing up to use the tool at www.data.bapen.org.uk Supporting the dietetic community

PENG acknowledges the importance of liaising with other Specialist Groups of the BDA to avoid duplication of efforts. Where possible, we seize opportunities to not only promote the work of dietitians in nutrition support, but also to promote the work of other Specialist Groups of the BDA to external audiences and stakeholders as they

ON BEHALF OF PENG

Recognising the pressing need to collect and utilise meaningful outcomes to protect practice and posts, a PENG project group is currently working to develop a practical toolkit on outcomes in nutrition support. arise, e.g. public health dietitians at a meeting with the Director of the Faculty of Public Health, paediatric dietitians at a Westminster forum on the role of diet in chronic conditions. In 2013/2014, PENG collaborated with the dietetic ‘virtual home enteral feeding (HEF) group’ to move the hosting of the virtual HEF group to PENG. The forum, an initiative developed by the Bristol Home Management Services for enteral feeding, had become a victim of its own success. The move was undertaken to secure ongoing support for this vibrant network to continue. Although now managed by PENG, the network is open to all healthcare professionals, including non-members, to enable a wide audience to access it (www.peng.org.uk/hef-group/). PENG hopes that this move will foster links with the NNNG and BAPEN’s BANs Committee via our PENG HEF leads. The network remains very active and is a great example of how a virtual professional forum can flourish and enhance the sharing of best practice, facilitate peer support and policy development. Monitoring activity will help identify gaps, which PENG may be in a position to address through funds and resources. Leading on the development of a multiprofessional, multi-organisation statement on the appropriate use of oral nutritional supplements is a recent initiative, which we hope discourages discrepancies and misunderstandings in oral nutrition support. In conjunction with BDA Head Office, PINNT, NNNG, respite nurses and the Paediatric Group of the BDA and DISC, PENG helped develop a statement on the use of liquidised feeds for tube feeding and a risk-assessment tool (www.peng. org.uk/pdfs/hcp-resources/risk-assessmenttemplate.pdf). Both are designed to guide practice and sensitively account for the views of all stakeholders, including patients and carers on this emotive topic. PENG was also represented on the BDA Supplementary Prescribing Group proposal and in a separate prescribing project group tasked to

consider the future management of borderline substances by dietitians. With presence at key BDA events such as BDA Vision, Dietitians Week and the BDA House of Lords event in June (where our jellybean-eating mannequin ‘Adam’ created a stir), 2015 was a busy year. Future proofing our profession outcomes in nutrition support

Recognising the pressing need to collect and utilise meaningful outcomes to protect practice and posts, a PENG project group is currently working to develop a practical toolkit on outcomes in nutrition support. Conscious of developments in other Specialist Groups, PENG is seeking to collaborate with other groups and therapists to minimise duplication and achieve our goal in a timely manner. Launch of the toolkit is planned for ‘BDA Live’ March 2016; more news will follow on this subject in a future article. For a large Specialist Group to be successful, it relies heavily on the volunteering of many. As Chair, I consider myself in a privileged position to oversee a strong, highly-skilled and dedicated team of Committee Members and Clinical Leads that give their time selflessly to deliver on objectives set to best support our Members. Whilst I have been unable to add names alongside all the projects, I hope you might visit the PENG website to see who is involved: www. peng.org.uk/about-us/peng-committee.php. The wide range of activities and achievements captured here illustrate the professionalism, dynamism and passion of the PENG Committee, Clinical Leads and Members and I wish here to thank you all. In future editions of NHD, I hope you will enjoy reading of new developments that will continue to ensure that good nutritional care is an integral part of modern healthcare and dietitians get the recognition they deserve. And you never know . . . you might be tempted to become a part of what we do. NHDmag.com February 2016 - Issue 111

career

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

DIETITIAN, MEDICAL AFFAIRS-MARKETING VITAFLO - LIVERPOOL, Full-time, 12-month, fixed-term contract (maternity leave) Vitaflo International Ltd are looking for a highly motivated dietitian to join our Medical Affairs Marketing team. We are seeking someone who will thrive in a dynamic, innovative environment, who has excellent communication skills, is flexible, self-motivated and enthusiastic. We offer a competitive remuneration package. Full training will be provided but clinical experience, particularly in metabolic disorders, would be a definite advantage. The successful candidate will use their technical/clinical knowledge, through the provision/ development of core tools and activities, to support the marketing of the Vitaflo product portfolio, particularly their assigned product range. The diverse aspects of the role include: Analysis, interpretation and dissemination of technical dietetic data, for in-house staff, to support the product range; Training of both UK and international personnel; Supporting new product launches; Keeping up to date with current clinical thinking; Answering technical queries on the nutritional helpline regarding Vitaflo products. Email your CV to chris.richards@vitaflo. co.uk or post to: Mr Chris Richards, HR advisor, Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool L3 4BQ. Closing date: Friday 19th February 2016. BAND 6 PAEDIATRIC DIETITIAN - SLOUGH - asap We are looking for an experienced Paediatric Dietitian to join this friendly team, for a three-months post. Covering general paediatric ward work on a full-time basis (37.5 hours per week). To be considered for this role or others with Elite, please email Hayley@eliterec. com or call 0800 023 2275 or 01277 849 649. Visit www. elitedietitians.com to register for our Job Alerts. BAND 5 COMMUNITY DIETITIAN - Nw england We are looking for a Band 5 Dietitian to join this community post ASAP. Covering adult community work and home visits, your own transport is desirable. To be considered for this role or others with Elite, please email Hayley@ eliterec.com or call 0800 023 2275 or 01277 849 649. Visit www.elitedietitians.com to register for our Job Alerts.

NHDmag.com February 2016 - Issue 111

BAND 6 RENAL DIETITIAN - EAST ANGLIA, ASAP We are looking for a Dietitian with significant renal experience who will be able to hit the ground running. Experience in haemodialysis, peritoneal dialysis, acute kidney injury, pre-dialysis, conservative management. A full-time post starting ASAP, it is expected to run for up to three months. To be considered for this role or others with Elite, please email Hayley@eliterec.com or call 0800 023 2275 or 01277 849 649. Visit www.elitedietitians.com to register for our Job Alerts. BAND 5/6 DIETITIAN - EAST ANGLIA Experienced Dietitian required for a month initially, starting as soon as possible. Essential experience required: general medical and surgical, plus older people’s medicine wards, general outpatient clinics. Desirable experience: previous working knowledge and experience of gastro and/or oncology or intensive care. Car not required. To be considered for this role or others with Elite, please email Hayley@eliterec.com or call 0800 023 2275 or 01277 849 649. Visit www.elitedietitians.com to register for our Job Alert.

events and courses University of Nottingham - School of Biosciences • Paediatric Nutrition - 10th & 11th March; 5th & 6th May 2016 • IBS and Low Fodmap Course - 21st April 2016

For further details please contact Lisa Fox via email on lisa.fox@nottingham.ac.uk or check out the University website at www.nottingham. ac.uk/biosciences and click on ‘Study with us’ and then ‘short courses’ which will take you to ‘for practising dietitians’. Nutricia Paediatric Allergy Symposium (FREE) 24th February 2016 Royal College of Physicians, London www.nhdmag.com/events BDA Live 2016 16th-17th March QEII Centre, London, www.bdalive.co.uk/

a day in the life of . . .

a new council member of the British Dietetic Association Belinda attended her first BDA Council meeting back in September 2015 and tells us what was involved, who attended and what was discussed…

Belinda Mortell Registered Dietitian Glan Clwyd Hospital

I currently work in the NHS as an Acute Dietitian, but have also worked in private practice and in public health in Ireland and Gibraltar. I have only been working in the NHS a year, but I am very happy with my decision to move into Acute Dietetics. I am PR & Media Committee Member of the North West England and North Wales branch of the British Dietetic Association (BDA) and Chair of the Communications and Marketing Board of the BDA. I have a background in Higher Education, Business Engagement and Finance and I have worked in management accounting for Unilever Best foods, O2Telefonica and ChevronTexaco. BDA Council

Belinda works for the Betsi Cadwaladr University Health Board, North Wales and is Chair of Marketing and Communications at the BDA.

As Chair of the Communications and Marketing Board, I also sit on the BDA Council and attended my first meeting back in September 2015. The Council is not only a professional body, it’s also a Trade Union too, responsible for strategic leadership, managing the finances and representing the membership. There are approximately 8,500 members. I had no experience of the workings of a council and faced a steep learning curve, having no idea how it operated. I also didn’t know anyone on the BDA Council. I joined the BDA as a full member on my return to the UK back in 2012, joining the local branch, but not interacting with the office at all. I had only visited the BDA offices once, and had no idea about the set up. I was previously a member of the Irish Nutrition and Dietetic Institute, being one of only 600 members.

initial meeting

My first face-to-face council meeting was in November at BDA Offices Birmingham, with 11 members of Council and four members of the BDA office present. Council members come from a diverse range of work areas, including acute dietitians, dietitians working in industry and freelance/ media specialists. There is also a dietetic support worker representative, a student representative and Trade Union lead. The room was full of immensely experienced and skilled dietitians, which made me feel very excited and honoured to be part of the BDA Council and hopeful for the future of the profession. on the Agenda

As Council has a responsibility for financial control of the association, BDA budgets and results from the previous year were analysed and approved. We discussed the online resource PEN, an online evidence resource free to access by BDA members. As the BDA is 80-years-old in 2016, we also went through plans for BDA events, which could incorporate this milestone. These included BDA Vision and BDA Live. HCPC (Health and Care Professions Council) developments which will impact BDA members were included on the agenda. We were asked to consider candidates for the BDA annual awards. New developments such as the launch of the BAPEN selfscreening tool and the launch of Eating well, living well, a BDA public facing magazine, were also discussed. NHDmag.com February 2016 - Issue 111

a day in the life of . . . European Federation of the Associations of Dietitians

Anne de Looy (Honorary president) explained the operations of EFAD. She reminded us that all BDA members are entitled to register with EFAD for free. EFAD works to promote the dietetics profession on a global level.

which includes the BDA 80th birthday, Trust a Dietitian and Dietitiansâ&#x20AC;&#x2122; Week. Key objectives for the board include: promoting the profession, ensuring the BDA engages with all external stakeholders, helping manage external affairs and be a reference point for the BDA office in the context of communications and marketing.

Sports and Exercise Nutrition Register

And finally

Rosanna Hudson, BDA Policy Officer, and Louise Sutton of the Sports and Exercise Nutrition Register (SENr), attended to present information concerning the policy for joining this register. The SENr is administered by the BDA and includes dietitians, nutritionists and sports and exercise nutritionists. Communications and Marketing Board

The Communications and Marketing Board meet three times a year in the Birmingham offices of the BDA. The board is in the process of identifying terms of reference and developing a work plan, with identifiable outcomes,

The most important thing I have learnt in the last three years since landing back in the UK is that networking is so important for developing your career. You never know who you might meet, so I would encourage anyone to introduce themselves to the person they are sitting next to at the next CPD event or conference they attend. In addition, I would encourage any dietitian, no matter their job title, NHS grade, age or experience, to engage with their member organisation, be a committee member for a branch or group, member or chair of council boards, offer to speak at events, take part in projects. You never know where it may lead.

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The final helping To weigh or not to weigh? Neil Donnelly weighs up the pros and cons of new pair of home scales!

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.

Until just recently, I couldn’t remember the last time I bought personal weighing scales. Working as a dietitian, it is extremely unlikely that you don’t have scales close by that you can use, in fact you can probably take your pick from a number and decide on the ones that you believe offer you your correct weight! At home it has been a different matter. A wife and three daughters have, over the years, taken numerous step-ups on our domestic variety, and slightly muted cries of anguish or delight have been heard on viewing the result. The scales we own need to be on a solid floor and, each time before weighing, the pointer is carefully confirmed to be at zero by, if necessary, adjusting a small cog on the base. On stepping on to the scales, the needle then travels around before eventually stopping at the person’s weight. You then make your judgement, in stones and pounds, where you think the needle has landed. Simple! And so it was until a few days after Christmas; I was in a supermarket topping up on a few essentials following the festivities. Along one aisle, which had an assortment of unrelated goods, there was a container of, you guessed it, digital scales, just ready for the after party season! They looked a little smarter than our traditional variety waiting for me at home and, of course, were ‘ultra slim’, which undoubtedly helps. I juggled with my thoughts for a minute or so and, finally, I thought that at £12.99 what have I got to lose? You can even use them on the carpet; all the family can have their personal data entry; they have an athlete mode for those

involved in intense physical activity; and they read your body fat percentage and of course measure your body water(!). Everyone’s a winner. Well not quite it seems . . . Firstly, it was the not getting a reading in stones and pounds, just pounds. The immediacy of seeing the pointer adjacent to the weight in figures rather than calculating the result in your head seemed to be preferred. Personal data… not sure about that! Athlete… well yes and no. Body fat… is this absolutely necessary? Body water! No thanks. All seemed to favour keeping this process very simple and that now too much emphasis was being placed on what was otherwise a fairly simple thought: how much do I weigh and how this relates to a normal ‘healthy weight’ as currently represented in BMI charts. So, the ‘old’ familiar comfortable scales have now been rescued from the loft and the new daunting, intrusive, confusing, ultra-slim arrival has been put to one side. Stepping onto any scales at this time of year can result in mixed emotions, but anyone wanting to monitor their weight/BMI needs not to fear the scales, but to use them as a good guide (and that includes maintaining a healthy weight) to their progress over an extended period of time. And finally, that means not every day but around once a week. Happy weighing! NHDmag.com February 2016 - Issue 111

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EXTRA

Issue 111 February 2016

ISSN 1756-9567 (Online)

"\ \'

Malabsorption

Beth Thompson

STUDENT CASE STUDY: Metabolic Syndrome Lori Warford-Woolgar

WEB WATCH RESOURCES AND UPDATES INTRODUCING OUR NEW EDITOR

EXTRA NHD ARTICLES FOR SUBSCRIBERS ONLY

Introducing NHD’s new Editor, Emma Coates . . . Emma will be taking up the post of NHD Magazine’s Editor from the March issue and here she tells us a bit about her dietetic background and what she hopes for the future of NHD. It’s great to have you on board Emma. Can you give us a brief outline of your dietetic background? I studied for my BSc (Hons) in Dietetics at Leeds Metropolitan University, graduating in 2006 and was fortunate to find my first job that year, at the Countess of Chester Hospital. For around two and a half years I worked there as a Band 5 Dietitian, completing an excellent rotation through many specialisms, including surgical, cardiology, respiratory, renal, diabetes and my personal dietetic interest, paediatrics. In 2008, a Band 6 paediatric position opened up at Wrexham Maelor Hospital, part of the Betsi Cadwaladr University Health Board (BCUHB) trust in North Wales, in my hometown. I jumped at the chance and applied. The following six years provided a large and varied paediatric caseload to manage in both the hospital and community setting. Whilst at BCUHB, I embraced many opportunities to develop and expand my skills as a dietitian, including becoming part of the student training team, a BDA trade union representative, writing for NHD Magazine and guest lecturing for the University of Chester. After eight and half years of working as an NHS dietitian, I moved into industry as metabolic dietitian/ brand manager for Dr Schar - Mevalia Low Protein. This is an exciting and challenging role where I manage the low protein brand for the company in the UK. My first year there been extraordinary, developing so many new skills and expanding my knowledge

greatly. I have no doubt that this next year with the company will bring even more opportunities to grow as a dietitian. What are the hot topics in dietetics at present? Depending on your specialism, anything can be a hot topic! However, the nutritional challenges at either end of the life span are always talking points. Getting the best nutritional start in life is vital, as seen by the evidence from the www.thousanddays.org campaign. In contrast, the management of elderly care nutrition is a key issue to discuss, as the ageing population is ever increasing. Keeping our nation healthy is always a source of great debate, whether it’s related to malnutrition (under nutrition) or the obesity/metabolic syndrome crisis. Amongst these discussions, there’s always the nitty gritty of how dietetics can offer efficient, effective, safe and value-for-money services. In the future, I see further developments in the use of ketogenic diets and possibly the role of nutrigenomics. How do you see the NHD community supporting healthcare professionals in the field of nutrition and dietetics? Over the years, NHD has been a great provider of current and relevant articles for the nutrition and dietetics community. Keeping abreast of hot topics and moving with the current trends, NHD is a good tool for topping up on the most recent information, research and guidelines in all things nutrition and dietetics. It provides an easy way NHDmag.com February 2016 - Issue 111

NHD’s new editor - NHD extra for dietitians and nutritionists to complete some CPD, learn something new, or just reinforce their current knowledge. Now, with excellent regular columns from contributors such as PENG and the NSPKU (IMD watch), as well as the great quality and variety of individual contributors we have, CPD has never been so easy or enjoyable! Does technology have a major role to play in the industry? Technology defines so much of what we do in our working lives. Accessing a wealth of information is a click of a button away, along with contacting or connecting with other dietitians and healthcare professionals around the world. The development and use of dietetic apps is growing and the role of social media has expanded over the last few years too. Having so much good quality information online at our fingertips, is a true feast for anyone with time to sit and read it! NHD Magazine has embraced technological developments to ensure it stays up to date and creates the most accessible routes for its readers. Our printed magazine is a handy digest size, compact enough to take along to clinics or on your commute to and from the office (not, however, if you’re driving!). Alternatively, if you prefer the paperless option, the NHD digital issues are great for reading on your smart phone

or tablet. Subscribers will be able to download this issue from our website (www.NHDmag.com) and will be able to print pages too. If it’s just a single article you’d like to read and keep, the magazine’s online CPD eArticle section is free for you to use - read the article, answer the questions, save and keep for your CPD portfolio. NHD is also part of the online social media community via Facebook and Twitter. Unless you live in a cave, being part of the NHD readership is just so easy. What’s your vision for NHD as you take over the role of Editor? I am keen for all of the magazine’s current accolades to continue, but also to welcome new contributors, giving more dietitians, nutritionists and other healthcare professionals an opportunity to develop their skills as writers and share their information, experiences and best practice. If you have an interest in writing for NHD, please email info@networkhealthgroup.co.uk. We would love to hear from you. Expanding our readership is important for me. Opening up NHD to students, dietetic assistants/technicians and nutritionists will hopefully encourage a new group of readers to enjoy all that NHD has to offer. Interaction with our readers is important; creating discussion and gaining feedback is key to the magazine’s ongoing success.

NH-eNews plus NHD eArticle with CPD

NHDmag.com February 2016 - Issue 111

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STUDENT DIGEST - NHD extra

CASE STUDY: METABOLIC SYNDROME In the first of our case studies written with students of Nutrition and Dietetics in mind, Lori Warford-Woolgar provides us with an example case of a 64-year-old male with Metabolic Syndrome.

Lori WarfordWoolgar Registered Dietitian and Nutrition Research Consultant

Approximately one in five adult Canadians have metabolic syndrome.1 A person with metabolic syndrome is twice as likely to die from heart attack or stroke and three times as likely to have a heart attack or stroke when compared to people who do not have metabolic syndrome.2 The International Diabetes Federation (IDF) defines metabolic syndrome as a condition in which a person has central obesity in addition to any two of the following factors: elevated triglycerides (TG), reduced high den-sity lipoprotein (HDL) cholesterol, elevated blood pressure and elevated

fasting plasma glucose (FPG).3 The IDF recommends that primary intervention for the management of metabolic syndrome includes moderate restriction of energy intake to obtain a 5.0-10% decrease in body weight in the first year, increased physical activity and dietary changes

Case study RW is a 64-year-old male who works as a mine shaft hoist operator. He lives with his wife of 40 years who enjoys cooking and baking and packs his snacks/ lunches for work. His job is sedentary and he typically works 12-hour days. RW is 5’9” (175cm) tall and weighs 222lbs (100.8kg). The lowest weight he has been in the last five years is 215lbs (97.6kg). Although he tries to run on his treadmill at home, exercise is sporadic and is not part of his usual routine. RW was recently diagnosed with impaired fasting glucose (IFG) with a fasting plasma glucose (FPG) of 6.8mmol/L and dyslipidemia with a reduced HDL of 0.75mmol/L. He was diagnosed with hypertension (132/72 treated) about five years ago and has had gastro-oesophageal reflux disease (GORD) for several years. RW is a non-smoker. He has a younger brother who survived a heart attack and underwent bypass surgery. RW’s current medications include Losaran 100mg OD to treat hypertension and Omeprazole 20mg BID to treat GORD.

Lori is a Registered Dietitian living in Canada. She has a Master’s Degree in Human Nutritional Sciences and enjoys critiquing nutrition research and analysing how the latest evidence can be applied to dietetic practice.

RW’s typical daily food intake: Breakfast: coffee with skimmed milk powder, two fried eggs and bacon, two slices wholemeal toast with non-hydrogenated butter and small glass of orange juice Snack: pudding cup (yoghurt/mousse) and apple Lunch: deli sandwich on wholemeal bread with lettuce, tomato and mayonnaise, chocolate chip cookies and tea with skimmed milk powder Snack: cheddar cheese, soda crackers and banana Supper: meat, potatoes, side vegetable and gravy or margarine, 1.0% milk and tea with skimmed milk powder and a bowl of cup of ice cream RW snacks before bed on processed cheese slices, ice cream, cookies and often has two evening drinks of rum and cola. RW admits he has a weakness for sweet foods. RW uses added salt at all meals.

NHDmag.com February 2016 - Issue 111

STUDENT DIGEST - NHD extra Identification of nutritional need 1. Assessment Medical diagnosis: Metabolic syndrome (hypertension, dyslipidemia, IFG, obesity), GERD Anthropometric measurements: Height 5’9” (175cm); weight: 222lbs (100.8kg); BMI=32 indicating obesity; waist circumference 46” indicating very high risk for Type 2 diabetes, hypertension and cardiovascular disease. Framingham Risk Score: 29.4% indicating high risk of cardiovascular event. Dietary Intake Analysis: Food frequency questionnaire revealed total energy intake is approximate 3,600 calories/day with 30% of calories from total fat, 12% of calories from saturated fat and 20% of calories from sugar. Sodium intake 4,800mg/day. Fibre intake 25g/day Recommended body weight: 121lbs (55kg)-165lbs (75kg) based on BMI of 18-24.9. Client is 57lbs (25.9kg) over high end of ideal body weight range Estimated energy needs: 2,200 calories/day based on ideal body weight of 165lbs using Harris-Benedict Equation with activity factor of 1.3. Client is consuming 1,400 calories/day more than estimated energy needs. To initiate gradual weight loss 3,100 calories/day is recommended (current energy intake of 3,600 calories/day - 500 calories/day). Nutrition Related Laboratory Values: FPG 6.8mmol/L, HDL 0.75mmol/L, blood pressure (treated) 132/72 Medications: Losartan 100mg OD, Omeprazole 20mg BID Readiness to change nutrition-related behaviours: Client is in the preparation stage of change. He monitors his blood glucose daily and is worried that he might develop Type 2 diabetes and/or have a heart attack. Client states morning FPG is usually 10mmol/L and two hours after a meal can range from 6.0-12mmol/L, which are slightly higher values than recommended by the Canadian Diabetes Association (FPG 4-7mmol/L and two hours post prandial 5.0-10mmol/L).4 Client is uncomfortable with his weight and is aware that he consumes too much sugary foods and requires more physical activity. Client admits that if he is aware there are sweets in the house it is difficult to resist the temptation of snacking on them in the evenings. Client is attempting to increase physical activity at home, but is finding it difficult to maintain a routine due to his long days at work. 2. Identification of nutrition and dietetic diagnosis Excess energy intake related to high fat and high sugar/sugary food consumption. Excess saturated fat intake due to fried foods, large meat portions, high fat snack foods and added fats. Excess sodium consumption related to added salt and select processed foods. Moderate fibre intake. Decreased physical activity. 3. Plan nutrition and dietetic intervention Nutrition prescription: 3,100 calories/day with 25% of calories from total fat, <7.0% of calories from saturated fat and 10% of calories from sugar. Limit sodium intake to 1,500-2,300mg/day. Increase fibre intake to 40g/day. Motivational Interviewing: Meet with client and his wife to discuss alternatives to evening sugary snacks, such as almonds and grapes with milk or homemade low sugar/high fibre muffin and cheddar cheese with tea. Recipes provided. Discussed limiting two drinks of rum and cola to one evening a week. Provided examples of healthier breakfast choices, such as porridge and banana with tea or boiled egg with wholemeal toast and glass of fresh orange juice. Discussed limiting the purchase of processed high fat and sugar foods. Suggested alternatives to salt in providing added flavour to foods and gave a list of how herbs and spices complement particular foods. Reviewed portion sizes using food models so client could relate to what a healthy portion looks like. Explored ways to incorporate moderate exercise while at work, such as going for walks during breaks.

NHDmag.com February 2016 - Issue 111

STUDENT DIGEST- NHD extra 4. Implement nutrition and dietetic intervention Provided sample meal plan and discussed benefits of increased fibre intake and decreased, energy, fat, sugar and sodium intake. Plan to return to nutrition outpatient clinic in two weeks for continued lifestyle change intervention. Provided instruction on how to record three-day food intake record, which is to be completed three days prior to next follow-up appointment. 5. Monitor and review On a bi-weekly basis, monitor and review weight at home, record blood glucose values and dietary intake with particular emphasis on the need for decreased intake of energy, fat, sugar and sodium with increased intake of fibre. Discuss physical activity and how to include on a regular basis. Recheck FPG, HgA1C, blood lipids and blood pressure in 3/12. 6. Evaluation First two-week follow-up: Client has decreased weight by one pound. Three-day food record indicates daily caloric intake has decreased by 500 Calories/day to 3,100 calories/day with 28% of calories from total fat, 9.0% from saturated fat and 16% from sugar. Sodium intake has decreased to 3,000mg/day. Daily at-home recorded blood glucose values indicate FPG of 8.0mmol/L and two-hour post prandial of 8.0-10mmo/L. Client has been walking during breaks at work. Client has shown improvement in all areas of dietary intake and physical activity. Plan is continue two-week follow-up appointments to encourage lifestyle change. References 1 Riediger ND, Clara I. Prevalence of metabolic syndrome in the Canadian adult population. CMAJ 2011; 184(15): E1127-E1134 2 Isomaa B, Almgren P, Tuomi T et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001; 24(4) 683-689 3 International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome. The International Diabetes Federation website. Available at: www.idf.org/webdata/docs/MetS_def_update2006.pdf. Accessed October 19, 2015 4 Canadian Diabetes Association (2013). Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. The Canadian Diabetes Association website. Available at: http://guidelines.diabetes.ca/fullguidelines. Accessed December 8, 2015

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MALABSORPTION - NHD extra

Malabsorption examined: what, where and how? Malabsorption is the term commonly used to describe the impairment of nutrient absorption, but it can also refer to the impairment of digestion, also known as maldigestion. It is the result of defects within either the membrane transport system or absorptive surface area of epithelial cells with in the small bowel.1 Beth Thompson Intestinal Failure and Acute Team Lead Dietitian, Royal Devon Exeter Hospital

There are three stages to normal nutrient absorption and malabsorption can occur at any of these (see Table 1). Malabsorption can be split into the terms ‘Global’ or ‘Isolated’ malabsorption.2 Global refers to malabsorption which occurs due to either diffuse mucosal involvement or a reduction in the absorptive surface of the small bowel. A good example of this is coeliac disease, where damage to the brush border of the small bowel results in the impaired absorption of nearly all nutrients. 3 At the extreme, signs of global malabsorption include: pale; greasy; large volume foul smelling stools, along with weight loss despite

adequate nutritional intake. However, many patients may present with symptoms which mimic disorders such as Irritable Bowel Syndrome, therefore diagnosis may prove difficult. Signs of a single nutrient deficiency, such as Iron Deficiency Anaemia, may be an indicator of global malabsorption.2 Isolated malabsorption occurs due to interference to the absorption of a specific nutrient. This may result from bowel surgery and bowel resections and can be indicated by low serum concentrations of a specific nutrient (e.g. low B12 levels resulting in pernicious anaemia).2 This article is going to concentrate on the malabsorption of carbohydrates and

Table 1: Stages of absorption and what malabsorption can occur there.

Beth has seven years’ experience working in Gastroenterology and Colorectal Surgery. She has been working with Intestinal Failure patients for the last two and a half years and enjoys the challenge of working with this complex patient group.

Stage

Malabsorptive defect

Condition example

Luminal phase: This takes place at the brush border of epithelia cells within the small bowel.

Deficiency in digestive enzymes Diminished bile salt synthesis Impaired bile secretion Bile salt de-conjugation Increased bile salt loss Diminished gastric acid Diminished intrinsic factor Bacterial consumption of nutrients

Chronic pancreatitis

Mucosal (absorptive) phase: This is where nutrients are absorbed into the intestinal mucosa

Problems with Epithelial transport

Coeliac disease

Postabsorptive, processing phase: This is where nutrients are transported into the circulation

Increased mucosal permeability, or lymphatic obstruction

Protein losing enteropathy

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Cirrhosis Chronic cholestasis Bacterial overgrowth Ileal disease or resection Atrophic gastritis Pernicious anaemia vitamin B12 Bacterial overgrowth

MALABSORPTION - NHD extra fats. However, there are some general dietary principals to follow to help manage patients with malabsorption. These mainly concentrate on managing the symptoms of diarrhoea which occur in many cases of malabsorption. The most important factor is to identify the cause and, therefore, working in conjunction with a gastroenterologist is vital. The general dietary principles include: • Limit caffeinated drinks - caffeine is a gastric stimulant and may increase the transit of nutrients, promoting diarrhoea. Intakes of one to three cups a day are recommended. If patients normally consume more, then having decaffeinated alternatives is recommended. • Limit fizzy, high sugar drinks. Again these can lead to increased volumes of diarrhoea. Diluting drinks with water may be beneficial if patients have difficulty in reducing their intakes. • Replenish lost salt by adding salt to foods and having high salt foods such as crisps. • Patients may benefit from an oral rehydration solution such as St Marks Solution or Diarolyte. Checking urinary sodium levels (result <20) may help indicate if this is required. • Increase patients’ energy intake. When patients are experiencing malabsorption, they may need to consume two to three times their estimated nutritional requirements to meet their nutritional needs. Therefore, there is a reliance on high energy foods and nutritional supplements may be beneficial. • Liaise with physicians about the use of antidiarrhoeals such as Loperamide. • In patients with known vitamin or mineral deficiencies, then supplementation at high levels may be required to replenish levels. Supplementation should be monitored for maintenance levels. Carbohydrate malabsorption

The most abundant carbohydrates in our diets are starch, sucrose and lactose. In order to be absorbed they need to be broken down into their monosaccharides and this occurs by both salivary and pancreatic amylase. For example, these enzymes break down starch into disaccharides and oligosaccharides which are then further degraded at the micro villus membrane. Here, brush border enzymes

(disaccharidases) hydrolyse the disaccharides into monosaccharides which are then absorbed by either active or passive processes. Malabsorption of carbohydrates can, therefore, result from deficiencies in amylase (mainly pancreatic amylase), decreased disaccharidase activity in the epithelium of the small bowel or by a reduction in the absorptive area. Any carbohydrates which are not digested and absorbed in the small bowel, undergo bacterial degradation in the colon. This leads to fermentation and formation of short chain fatty acids, along with carbon dioxide, hydrogen and methane. When excessive fermentation occurs, it can lead to abdominal distension, excessive wind and acidic stools. The diagnostic test for carbohydrate malabsorption is a hydrogen breath test. A malabsorption diagnosis is evidenced if the result is more than 20 parts per million above the patients baseline. This test is commonly used to diagnose lactose malabsorption.4 Lactose malabsorption

Lactose is the main sugar in all animal milk. Lactose malabsorption is thought to be more common in people from India and South East Asia than people from northern Europe.5 In most people, the enzyme lactase has a reduced activity at the brush border once weaning has occurred and this reduced activity can cause symptoms after lactose indigestion. It is important to distinguish that malabsorption with regards to lactose refers to the inefficient digestion due to low lactase levels or other GI pathologies, whereas lactose intolerance refers to the symptoms caused by lactose malabsorption. These symptoms can range from diarrhoea, nausea, bloating, borborygmi, and abdominal pain.6 However lactose malabsorption has also been associated with skin disease, rheumatological complaints, chronic fatigue and failure to thrive in children. Following a lactose-free diet will improve symptoms; however, in some cases, looking at the underlying disease may improve lactose absorption. For example, patients with small bowel Crohn’s disease are more likely to experience lactose intolerance than those with colonic Crohn’s. This is because it may occur due to bacterial overgrowth or increased transit, both of which may resolve with treatment.7 NHDmag.com February 2016 - Issue 111

MALABSORPTION - NHD extra Table 2: Lactose and calcium content of different milk products Food

Serving size

Lactose/calcium

Milk, full fat

1cup, 250ml

12g/285mg

Milk, semi-skimmed

1cup, 250ml

13g/340mg

Yoghurt, full fat

200g

9.0g/340mg

Yoghurt, low fat

200g

12g/420mg

Cheese, cheddar

30g

0.02g/260mg

Cheese, cottage Butter Ice cream

30g

0.1g/22mg

1 teaspoon

0.03 /1.0mg

2 scoops

50g/ 55mg

The dietary principles of managing lactose intolerance are as follows: • Reduce lactose intake to <12g/day (if taken with other food, patients may tolerate up to 18g/day). • If having lactose-free alternatives such as soya, rice and oat milk, ensure that they are fortified with calcium. • To ensure adequate calcium intakes, encourage intakes of calcium-containing foods such as: bread, dried fruit (figs), nuts, seeds, fish with edible bones and green vegetables such as broccoli.8 Fructose malabsorption

Like lactose, fructose intolerance arises from the symptoms caused by fructose malabsorption. Fructose is highly fermented by bacteria in the gut which in some individuals leads to increased gas production, increased osmotic load and alterations in bowel habit, resulting in diarrhoea. Recent research has shown that up to half the population cannot not completely absorb a loading does of 25g of fructose when tested by a hydrogen breath test.8 This appears to be more predominant in those who have a functional gut diagnosis such as Irritable Bowel Syndrome (IBS), a fact that has contributed to the success of the Low FODMAP diet in IBS treatment.9 Fructose in our diets appears in two forms, on its own as a monosaccharide and in its disaccharide form, sucrose. It is not known why, but fructose in its disaccharide form is more easily absorbed than in its monosaccharide form, which, therefore, suggests that it is not only the amount of fructose consumed which affects its absorption, but also what it is consumed with. Research has shown that fructose absorption is increased if it 8

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is consumed along with glucose, galactose and some amino acids, but its absorption is reduced if it is consumed with sorbitol.10 The dietary recommendations for fructose malabsorption are, therefore, to avoid: • fruits high in fructose, such as apples, pears, nectarines, peaches, plums, apricot, blackberry’s, watermelon and cherries; • have moderate amounts of other fruits - three portions a day, e.g. 1 banana, 1 orange, 10 grapes; • honey; • sugar-free items - generally these will contain sorbitol; • jams, yoghurts and spread that contain fructose - fructose syrup, glucose-fructose syrup, and high fructose corn syrup. Fat malabsorption

Dietary fat mostly consists of triglycerides and digestion beginning in the upper GI with mastication and gastric mixing. The fat then undergoes hydrolysis by gastric lipase in the stomach and pancreatic lipase in the duodenum. It is these enzymes which break triglyceride molecules down into a two-monoglyceride and two fatty acid molecules. Bile salts then mix with these molecules to form liposomes, which are easily absorbed by enterocytes in the first two thirds of the jejunum. The bile salts themselves are not absorbed, instead they enter the rest of the intestinal tract, where they are reabsorbed in the terminal ileum.11 Fat malabsorption presents as foul smelling, pale stools known as steatorrhea. Patients can experience this if they lack the necessary enzymes for fat digestion, or because they have a reduced absorptive area. Patients with short bowel syndrome are likely to experience a degree

MALABSORPTION - NHD extra Table 3: MCT Sip feeds and Shots Presentation

Kcal/ml

Protein g/ml

MCT%

Survimed® OPD Drink

200ml bottle

1.0

0.05

47.5

Vital® 1.5kcal

200ml bottle

1.5

0.07

63.6

Fresubin 5kcal Shot

120ml bottle

5.0

25.8

Liquigen

250ml bottle

4.5

96.4

400g can

0.9

0.03

MCT Pepdite 1+ Table 4: MCT Enteral Tube Feeds

Presentation

Kcal/ml

Protein g/ml

MCT%

Fresubin® HP Energy

Easybag

1.5

0.08

56.9

Reconvan®

Easybag

1.0

0.06

57.6

Survimed® OPD

Easybag

1.0

0.05

51.4

Survimed®OPD HN

Easybag

1.33

0.07

51.9

Tin

1.0-1.5

0.04-0.05

25.5

Peptamen® HN

Smartflex™

1.3

0.07

69.4

Peptamen® AF

Smartflex™

1.5

0.09

52.3

Peptamen®

Smartflex™

1.0

0.04

70.3

Nutrison Peptisorb

Glass bottle

1.0

0.04

47.1

Nutrison MCT

Glass bottle

1.0

0.05

60.6

Vital® 1.5kcal

RTH bottle

1.5

0.07

63.6

Perative®

RTH bottle

1.3

0.07

400g can

0.9

0.03

Modulen®

MCT Pepdite 1+

Table 5: Fat-free Sip Feeds & Shots Presentation

Kcal/ml

Protein g/ml

Fat g/ml

Ensure Plus juce

220ml bottle

1.5

0.05

Fresubin Jucy Drink

200ml bottle

1.5

0.04

Fortijuce

200ml bottle

1.5

0.04

Resource® Fruit

200ml bottle

1.3

0.04

ProSource Liquid

30ml pouch

3.3

0.33

of this if they have less than 100cm of jejunum left. Patients’ who have had their terminal ileum removed, may experience steatorrhea due to their inability to reabsorb bile salts (12). Patients with this usually respond to cholestyramine; however, those with a reduction in their terminal ileum may also experience bacterial overgrowth, which can defunction bile salts resulting in fat malabsorption. An empirical course of antibiotics can be used as treatment if this occurs.13 Those who malabsorb fat due to a lack of enzymes usually have pancreatic insufficiency. This can be tested for by a faecal elastase test (<100ug Elastase/g stool = severe insufficiency)

and, therefore, have enzyme replacement therapy.14 This needs to be tailored to the patient who must be educated on identifying fat sources in their diets and the timings of the medications.15 There are no guidelines for the use of pancreatic enzymes, but it is recommended that doses are adjusted according to body weight and reported symptoms: • 500-2,500 units of lipase per kg body weight per meal • ≤10 000 units of lipase per kg/body weight per day • ≤4,000 units of lipase per g of dietary fat per day.16 NHDmag.com February 2016 - Issue 111

MALABSORPTION - NHD extra In addition, the following recommendations for taking pancreatic enzymes are: • taken with meals and snacks containing fats, protein and carbohydrates (not simple sugars); • taken at the start of meals and with snacks or nutritious drinks; • only taken with cold drinks as hot ones may make them less effective; • for large meals or meal times lasting longer than 30 minutes take half the enzyme dose at the start of the meal and half in the middle of the meal. In those experiencing fat malabsorption, a trial of reducing long chain fatty acids to less than 40g/day is thought to help reduce stool volume and fat content. This, however, may result in an inability to consume sufficient calories. Diets can be supplemented with medium chain fatty acids (MCT), to boost calorie intakes, but some MCT based supplements can cause nausea and osmotic diarrhoea so their use has to be carefully monitored.17 If fat malabsorption occurs due to short bowel syndrome, then the use of MCT is recommended in those who have a colon insitu, as this is their main absorptive site.18 Patients with fat malabsorption may experience a reduction in the absorption of fat

soluble vitamins (A, D, E and K). The excessive fatty acids in the intestinal lumen which occur due to malabsorption can bind to calcium and magnesium causing a loss of these minerals, therefore, monitoring of these levels should take place on a regular basis. If these are calcium and magnesium low, then parathyroid (PTH) function testing should take place. Low magnesium can lead to low PTH, which in turn lowers calcium, therefore, supplementing magnesium may help to increase calcium levels. Calcium levels should also be monitored when supplementing vitamin D, as this can cause increased calcium levels.19 In summary, malabsorption is the impairment of nutrient absorption. It can arise from impaired enzyme activity, a reduction in the absorptive area or a disturbance to the epithelial cells in the small bowel. Management should concentrate on identifying the cause of the malabsorption and, therefore, working with the clinicians is vital. The dietitian’s role is to help aid symptom management and, once a diagnosis has been made, to educate the patient on the best dietary treatment to ensure their nutritional status is maintained. Treatment may involve education on food restrictions, the use of enzyme replacements and the supplementation of micronutrients.

References 1 Z Vaníčková et al (2012). New trends in classification, monitoring and management of gastrointestinal diseases handbook - Screening and confirmation of malabsorption The 12th EFLM Continuous Postgraduate Course in Clinical Chemistry book 2 Keller J, Layer P (2014). The pathophysiology of malabsorption, Viszeralmedizin Gastrointestinal medicine and surgery 30:150-154 3 Fasano A, Catassi C (2001). Current approaches to diagnosis and treatment of celiac disease: An evolving spectrum 120, 3:636-651 4 Lindberg DA (2010). Hydrogen breath testing in adults: what is it and why is it performed. Vol 33/2(8-13), 1042895X 5 Misselwitz B et al (2013). Lactose malabsorption and intolerance: pathogenesis, diagnosis and treatment. United European Gastroenterology Journal 1(3) 151-159 6 Hammer F (2012). Diarrhea caused by carbohydrate malabsorption. Gastroenterology clinics of North America, vol. 41, no. 3, p. 611-627 7 Zhao, J. (2010) Lactose intolerance in patients with chronic functional diarrhoea: the role of small intestinal bacterial overgrowth Aliment Pharmacol Ther 31, 892–900 8 Allergy UK [online] http://www.allergyuk.org/common-food-intolerances/dairy-intolerance#non-dairy-sources-of-calcium (accessed 2015) 9 Shepherd, S (2006) Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for Effective Dietary Management Journal of the American Dietetic Association Volume 106 (10):1631–1639 10 Kyaw, M et al (2011) Fructose malabsorption: true condition or a variance from normality. Journal of clinical gastroenterology, vol. 45, no. 1, p. 16-21 11 Truswell, M et al (1988) Incomplete absorption of pure fructose in healthy subjects Am JC/in Nuir l988;48: 1424-30. 12 Gracie, D ,et al. (2012) Prevalence of, and predictors of, bile acid malabsorption in outpatients with chronic diarrhea. Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society, vol. 24, no. 11, p. 983 13 Quigley, E. and Small, M. (2014) Intestinal bacterial overgrowth: what it is and what it is not Current opinion in gastroenterology, vol. 30, no. 2, p. 141-146 14 Fieker , A. (2011) Enzyme replacement therapy for pancreatic insufficiency: present and future Clinical and Experimental Gastroenterology 2011:4 55–73 15 Domínguez-Muñoz et al (2011) Pancreatic exocrine insufficiency: Diagnosis and treatment Journal of Gastroenterology and Hepatology 26 (2); 12–16 16 Stallings VA, et al (2008). Evidence-Based Recommendations for Nutrition Related Management of Children and Adults with Cystic Fibrosis and Pancreatic Insufficiency: Results of a Systematic Review. J American Diet Assoc.; 108: 832-839. 17 Meiera, R. (2006) ESPEN Guidelines on Enteral Nutrition: Pancreas Clinical Nutrition 25, 275–284 18 Tappenden, K. (2014) Pathophysiology of Short Bowel Syndrome: Considerations of Resected and Residual Anatomy Journal of Parenteral and Enteral Nutrition Volume 38(1): 14S–22S 19 Edmée C.et al, (2013) The prevalence of fat-soluble vitamin deficiencies and a decreased bone mass in patients with chronic pancreatitis Pancreatology Vol 3:238–242

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resources & guidance

web watch Online resources and useful updates. Visit www.NHDmag.com for full listings. Physical activity in the UK: future plans ActiveUK has published Blueprint for an Active Britain, a report which sets out clear and achievable recommendations to get the nation moving. www.ukactive.com/ policy-insight/blueprint-for-anactive-britain Giving children a healthy start in life The Local Government Association has published Healthy beginnings: Giving our children the best start in life focusing on how councils from across the country intend to develop their plans following the transfer of public health commissioning responsibilities for under-fives to local government. www.local.gov. uk/documents/10180/6869714/ L15-430+Healthy+Beginnings+-+G iving+our+children+the+best+start +in+life/9758666a-1b31-40e7-bc8562751bc13a35 Tackling childhood obesity NHS Clinical Commissioners has published Local solutions to national challenges putting forward a series of key ‘asks’ to policymakers, regulators and the government, aimed at giving CCGs the freedoms and flexibilities they need to transform healthcare for their local populations and concentrate on the big issues: sickness prevention, health inequality and healthcare targeted to the needs of the patient. www.nhscc.org/latest-news/ localsolutions/

European Food and Nutrition Action Plan 20152020 The World Health Organisation Regional Office for Europe has published European Food and Nutrition Action Plan 2015–2020 intended to significantly reduce the burden of preventable diet-related non-communicable diseases, obesity and all other forms of malnutrition still prevalent in the WHO European Region. www. euro.who.int/en/publications/ abstracts/european-food-andnutrition-action-plan-20152020 DIET PILLS WARNING The Medicines and Healthcare products Regulatory Agency are warning of the dangers of buying diet pills online. When considering whether to buy a product that describes itself as herbal or natural, consumers are advised to look for products that display the Traditional Herbal Registration (THR) logo and a THR/PL number. These products have been assessed by the MHRA. www.gov.uk/government/news/ dangerous-diet-pills-not-the-answerto-new-years-resolutions

Change4Life Sugar Smart app Public Health England has developed a Change4Life Sugar Smart app to raise awareness of how much sugar is contained in everyday food and drink. The app works by scanning barcodes and revealing total sugar in cubes or grams. itunes. apple.com/gb/app/change4lifesugar-swaps/id1015850256?mt=8

NICE guidance: Care of dying adults in the last days of life This guideline (NG31) aims to improve end of life care by communicating respectfully and involving the patient and the people important to them, in decisions and by maintaining their comfort and dignity. It also covers how to manage common symptoms without causing unacceptable side effects and maintain hydration in the last days of life. www.nice.org. uk/guidance/ng31 NICE guidance: Intravenous fluid therapy in children and young people in hospital This guideline (NG29)covers general principles for managing intravenous (IV) fluids for children and young people under 16 years, including assessing fluid and electrolyte status and prescribing IV fluid therapy. www.nice.org.uk/guidance/ng29 Allied Health Professionals: interventions to improve public health Public Health England has published The role of Allied Health Professionals (AHPs) in public health: examples of interventions delivered by AHPs that improve the public’s health. This report describes the key findings of work carried out by a team of academics led by Sheffield Hallam University. www.gov.uk/government/ publications/allied-healthprofessionals-interventions-thatimprove-public-health

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