NHD March 2016 issue 112

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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

March 2016: Issue 112

sports nutrition for performance Infant weaning Dysphagia: Thickeners irritable bowel syndrome cystic fibrosis

Nutrition & Hydration Week 14th-20th March 2016

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.

NEWS

Food for thought Ending childhood obesity Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd Dr Emma Derbyshire is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health. www.nutritionalinsight.co.uk hello@nutritionalinsight.co.uk

The World Health Organisation has published a new report about how to put an end to childhood obesity. It has been estimated that around 70 million children aged five years or under will be overweight or obese by 2025. In turn, this has far-reaching effects on children’s health, educational attainment and quality of life.

The new report concludes that obesity prevention and treatment requires a holistic, ‘whole-of-government’ approach, including the formulation of new policies across all public sectors. A comprehensive list of recommendations is included, which are largely categorised under six key areas:

If you have important news or research updates to share with NHD, or would like to send a letter to the Editor, please email us at info@networkhealthgroup.co.uk We would love to hear from you.

1) 2) 3) 4)

Promote the intake of healthy foods Promote physical activity Preconception and pregnancy care Early childhood diet and physical activity 5) Health, nutrition and physical activity for school-age children 6) Weight management (Figure 1) In total, there are 36 key recommendations, with 13 of these falling under the category of ‘early childhood diet and physical activity’. This includes four breastfeeding policies and two actions to reduce high-sugar intakes in children.

Further actions and responsibilities are also set out to support the implement-

Figure 1: WHO Recommendations to end child obesity fall under five key areas

Source: WHO (2016)

ation of these. This includes actions for the World Health Organisation itself, international organisations, member states, non-governmental organisations, private sectors, philanthropic foundations and academic organisations.

In summary, the report concludes that child obesity is an established risk factor for adult obesity and ill health.

It concludes that only by working together and taking a multisector approach will we be able to tackle the ongoing problem of childhood obesity. Let’s hope that the pending UK National Obesity Framework adopts a similar outlook, taking obesity just as seriously with aligned policies where we can work together to put an end to childhood obesity.

For more information, see: World Health Organisation (2016). Report of the Commission on Ending Childhood Obesity. WHO: Geneva . Available here . . .

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of good nutrition and hydration in maintaining better health and wellbeing and improving recovery from illness or injury and in the management of long-term conditions; • taking into account the duties placed on them under the Equality Act 2010 and reducing health inequalities, duties under the Health and Social Care Act 2012. Also that service design and communications should be appropriate and accessible to meet the needs of diverse communities (www.england.nhs.uk/about/gov/equalityhub/legal-duties/).

Expected key outcomes

The real focus of the key outcomes is related to commissioners understanding the needs of their local population and the subsequent burden of malnutrition and dehydration on that population and the wider health economy.

Commissioners are encouraged to identify and review current services and to develop and improve trajectories, which will embed sustained improvements across the system. It is through this understanding that commissioners will be able to target resources to have maximum impact.

In order to achieve this, 12 key outcomes have been identified and it is hoped that these will be achieved by 2018. The key outcomes are: 1. To identify a local senior/executive champion who can drive the work forward and influence key stakeholders to make improvements.

2. Understand the local burden of malnutrition and hydration and commission services as identified by this evaluation.

3. Review existing service provision and agree improvement trajectories.

4. Commission services that: a. identify ‘at risk’ populations that include the needs of a diverse community and reduce health inequalities; b. implement appropriate interventions and evaluate their effectiveness; c. develop and implement strategies to prevent malnutrition and dehydration; d. connect hospital and community services to deliver an integrated nutritional and hydration pathway of care across the health economy;

5.

6.

7.

8.

9.

e. strengthen families’ and patients’ resilience by learning about prevention, maintenance and management of nutrition and hydration; f. incorporate, for children and young people, the psychological, emotional and interactional aspects of feeding relationships to ensure adequate intake.

Commission a workforce that has the necessary skills and capacity to undertake identification, prevention and intervention to reduce burden of malnutrition and dehydration.

Increase public awareness of the importance of good nutrition and hydration and of the local services available to provide support if needed.

Maximise opportunities for working across health and social care using the Care Act (2014).

Define clear outcomes for ‘at risk’ populations to ensure that any commissioned interventions are sustained.

Consider how data systems can be optimised to permit monitoring and evaluation. www.NHDmag.com March 2016 - Issue 112

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AD SPACE

REFERENCES: 1. Huynh DTT et al. J Hum Nut Diet. DOI 10.111/jhn.12306 Published online 25th March 2015. 2. Data on file. Abbott Laboratories Ltd., 2007 (PaediaSure Plus & PaediaSure Plus Fibre taste testing). 3. Data on file.

Abbott Laboratories Ltd., 2013 (PaediaSure Fibre taste testing). 4. Data on file.

Abbott Laboratories Ltd., 2013 (PaediaSure & PaediaSure Peptide vs. Peptamen Junior Powder). *Independent, head-to-head taste testing for PaediaSure, PaediaSure Plus, PaediaSure Fibre, PaediaSure Plus Fibre and PaediaSure Peptide vs. Fortini or Frebini Energy or Peptamen Junior Powder Date of preparation: July 2015 RXANI150120

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PAEDIATRIC

INFANT WEANING: GETTING THE BEST START Emma Coates RD Emma has been a Registered Dietitian for almost 10 years. For eight and half years she worked in the NHS, gaining experience of both adult and paediatric patient care. She is currently a company dietitian/ brand manager for Dr Schär UK and has recently joined NHD Magazine as Editor.

Weaning (or complementary feeding*) is that wonderful stage in an infant’s development where solid foods (often referred to as complementary foods) are introduced into the diet alongside breast milk or infant formula. Here, NHD Editor Emma Coates looks at the guidelines, recommendations and key research surrounding infant weaning.

A time often eagerly anticipated by many parents, weaning is important for developing social and physical skills, such as learning to interact with others at mealtimes, hand-to-eye coordination and the development of speech through the use of key facial muscles when chewing. It is also essential nutritionally as it prevents macro and micronutrient deficiencies at the time when breast milk and infant formula become insufficient as a sole source of nutrition at around six months (26 weeks) of age.

The ‘weaning window’ (between four and six months, or 17 weeks and 26 weeks) is the blank canvas where feeding behaviour, food preferences, future long-term health outcomes and even the risk of allergy are determined. Over the last 25 years, infant feeding research has uncovered the startling importance of giving our infants the best nutritional start in life; however, recommendations and guidelines remain confusing and inconsistent at times. It’s no wonder that ‘getting the best start’ really is at the forefront of many parent’s and healthcare professionals’ minds. * Complementary feeding - the preferred term for ‘weaning’ because ’weaning’ traditionally marks the reduction of breastfeeding1

What do the guidelines and recommendations say?

Current infant feeding guidelines and recommendations have evolved over many years. The Department of Health Committee on Medical Aspects of Food

Policy (COMA) - Dietary Reference Values were published in 1991.2 Giving the estimated daily energy and nutrient requirements for a range of ages across the lifespan, this document gave guidance on the safe nutritional intakes for infants from birth to one year of age, but no recommendations for the optimum age for weaning.

These recommendations were based only on infants who were formula fed.

COMA later produced the ‘Weaning and the weaning diet’ report in 19943 recommending that solid foods should be introduced into the term infant’s diet between four to six months of age. However, as early as 1974, COMA recommended that: ‘Breastfeeding is the best form of nutrition for infants. Mothers should be supported and encouraged in breastfeeding for at least four months and may choose to continue as the weaning diet becomes increasingly varied. The majority of infants should not be given solid food before the age of four months and a mixed diet should be offered by the age of six months.’3 As well as UK based guidelines and recommendations, international documents are also considered. Over the years, UK infant feeding guidance hasn’t always fully reflected international guidelines and recommendations. The World Health Organisation’s (WHO) report on the optimal duration of exclusive breastfeeding (2001)4 recommended that ‘exclusive breastfeeding for six months confers several benefits on the infant and the mother, and complementary www.NHDmag.com March 2016 - Issue 112

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PAEDIATRIC foods should be introduced at six months of age (26 weeks) while continuing to breastfeed’.

In 2001, the Scientific Advisory Committee on Nutrition (SACN) considered the 2001 WHO recommendations and concluded that, although breastfeeding until six months of age was nutritionally adequate, there should be scope for weaning to take place between four and six months of age.5 In 2003, the Department of Health updated its recommendations and stated that the introduction of solid food should be ‘at around six months’.6 The optimum weaning age

The optimum weaning age has been the subject of debate throughout the subsequent production and publication of infant feeding recommendations, guidelines and research.

Despite the publication of such documents it has always been common to find parents introducing solid foods earlier than four months of age. There is also the questionable relevance of the international guidelines within developed countries such as the UK. NHD Magazine_0515.ai 1 5/6/15 6:14 PM International guidelines are intended for safe

infant feeding practices within both developed and developing countries. Where infant mortality from contaminated weaning foods is much more of a reality than in developed countries, exclusive breastfeeding up until six months of age is highly recommended as the safest option. However, in the UK this is less of a concern and many query if withholding the introduction of solid foods until six months of age is strictly necessary.

Treating babies as individuals and tuning in to their readiness to start weaning should be factored into the advice given by healthcare professionals.

Babies develop at different rates with several factors contributing to their readiness to begin taking solid foods, for example, gestational age, physical and cognitive development. Parental choice as well as social and cultural influences must be taken into consideration also. Going forward there have been additional guidelines and recommendations to support the four to six month ‘weaning window’, with greater flexibility for parents to start weaning.

Table 1 shows a summary of infant feeding guidelines, recommendations and key research over the last 25 years.

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Table 1: Summary of infant feeding guidelines, recommendations and key research Document DH COMA Dietary Reference Values for UK report2

Year of publication

Key findings/recommendations

1991

Gave recommendations for safe nutritional values for energy and nutrients for infants aged birth to one year.

Based on bottle-fed infant data only.

DH COMA Weaning and the weaning diet report3

1994

Solid foods should be introduced into the term infant’s diet between four to six months of age.

WHO report on the optimal duration of exclusive breastfeeding4

2001

Exclusive breastfeeding for six months.

Solid foods should be introduced at six months of age while continuing to breastfeed.

2001

Breastfeeding is nutritionally adequate as a sole source of nutrition up to six months of age.

There should be flexibility to introduce solids.

Not before four months of age.

2001

Systematic review.

Acknowledged that breastfeeding for first six months of life is sufficient for many infants.

Some may require complementary feeding earlier.

Concerns regarding the increased risks of micronutrient deficiencies in those not weaned before six months of age.

2002

Concerns regarding the increased risks of micronutrient deficiencies in those not weaned before six months of age.

2003

All mothers should have access to skilled support to initiate and sustain exclusive breastfeeding for six months and ensure the timely introduction of adequate and safe complementary foods with continued breastfeeding up to two years or beyond.

Governments are responsible for the development and implementation of a comprehensive policy on infant and young child feeding, in the context of national policies for nutrition.

2003

Update following SACN 2001 recommendations.

Complementary feeding should commence at ‘around six months’.

SACN Committee Meeting5

Lanigan et al7

Butte et al8 WHO Global strategy for infant and young child feeding9

DH Infant Feeding Recommendation6 Committee on Nutrition Complementary Feeding: A Commentary by the ESPGHAN Committee on Nutrition10 SACN Subgroup on Maternal and Child Nutrition (SMCN): The Influence of maternal, fetal and child nutrition on the development of chronic disease in later life11

2008

Literature review.

Breastfeeding for about six months is a desirable goal.

Complementary feeding should not be introduced before four months and not later than six months.

2011

Recommended strategies to promote, protect and support exclusive breastfeeding.

Recommendation six from the report: ‘Strategies that promote, protect and support exclusive breastfeeding for around the first six months of an infant’s life should be enhanced, and should recognise the benefits for long-term health.’

2011

More recent infant growth data from the UK-WHO Growth Standards (RCPCH, 2011)13 used Separate values are provided for breast-fed and breast milk substitute-fed infants.

Values are also given for when the method of feeding is mixed or not known.

10-14% higher at 0-3 months but are lower by between 7-18% for infants after three months of age compared to the COMA 1991 values.

SACN Dietary Reference values for Energy12

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PAEDIATRIC British Dietetic Association (BDA) Policy Statement: Complementary feeding: Introduction of solid food to an infant’s diet14

2013

Paralleling DH 2003 recommendations.

Exclusive breastfeeding from birth.

Introduction of solid foods at around six months of age.

Infants should be managed individually due to developmental differences.

Consider parental opinion.

2014

Most babies are ready to wean between five and eight months of age.

It is best to wait until they are at least three months corrected age so that they can develop enough head control.

Few babies are ready to wean at five months, start to look for signs that the infant may be ready.

Government guidelines recommend weaning is not advised before six months, however, premature babies are not included in these guidelines.

Due 2016

awaiting amendments and revisions. awaiting amendments and revisions. smcn considering the Draft final report of the who commission on ending childhood obesity (2016) www.who. int/end-childhood-obesity/final-report/en/

BLISS: Weaning your premature baby. 8th edition15

SACN Subgroup on Maternal and Child Nutrition (SMCN): Review of complementary infant and young child feeding

The 1,000 days campaign

‘Good nutrition in the 1,000 days between a woman’s pregnancy and her child’s second birthday sets the foundation for all the days that follow.’16 The 1,000 days campaign promotes the improvement of nutrition for both mother and infant during the first 1,000 days of the infant’s life. Improving nutrition and preventing malnutrition during this critical window of development, which includes during pregnancy and the infant’s first two years of life can ‘program a person’s ability to regulate weight and affects brain development’.17 The effects of poor nutrition in early life leaves lasting damage, which may also affect future generations.18 By investing in better nutrition, the 1,000 days campaign also concludes that: 1. women who are well-nourished before and during pregnancy are less likely to die during childbirth; 2. ensuring that mothers are able to breastfeed and babies receive only breastmilk for the first six months of life, the lives of almost one million children can be saved; 3. faltering growth and stunting can be prevented, along with nutritional deficiencies such as iron deficiency anaemia; 4. the risks of non-communicable disease, e.g. diabetes, heart disease and obesity can be reduced in later life; 5. educational achievement can be improved.

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For more information about this campaign and its activities visit www.thousanddays.org/ (accessed Feb 2016) What about allergies?

Weaning can be an anxious time for parents as well as an enjoyable one. Food allergy is often discussed with healthcare professionals when parents are preparing to wean their child.

Approximately 6% of children in the UK will develop food allergies.19 The EAACI (European Academy of Allergy and Clinical Immunology) published their primary prevention of food allergy guidelines in 201420 which stated that avoiding complementary feeding beyond four months of age is not required. With regards to encouraging or withholding the exposure to allergenic food stuffs after four months of age, there is limited evidence to justify recommendations either way, irrespective of the family history of allergy.

However, in 2015, the eagerly awaited results of the LEAP study were published suggesting that early exposure to allergens such as peanuts can help to reduce the incidence of food allergy.21 However, more research is needed in this area to alter any current recommendations on the prevention of food allergy. A further allergy and weaning study is in progress. The EAT (Enquiring about Tolerance) study is looking in to how food allergy can be prevented.

Approximately 1,300 families have been recruited for the study, which is to be conducted by researchers at King’s College and Guy’s and St Thomas’ Foundation NHS Trust, London. The study will take place over the next three years and is aiming to discover whether the early introduction of certain foods into an infant’s diet alongside breastfeeding could prevent the development of food allergies.

Infant feeding is a complex issue and there is evergrowing evidence to suggest that the better the start, the better the outcome. Growth and development in the first two years of an infant’s life is miraculous and infants require the best quality nutrition to ensure that they reach their potential. Our infant feeding guidelines and recommendations require consistent reviewing and tailoring to consider our ever-evolving knowledge base. However, it is key to remember that guidelines and recommendations won’t fit with everyone’s views and opinions.

Future infant feeding guidance should include support and guidance for parents choosing infant formula as current guidance mostly focuses on breastfed infants. As healthcare professionals we must bear this in mind, supporting and guiding parents/carers in their feeding choices to the best of our ability.

References 1 World Health Organisation. Complementary feeding of young children in developing countries: a review of current scientific knowledge. Geneva, Switzerland: World Health Organisation, 1998 2 DH. Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. Report on Health and Social Subjects No 41. London: Her Majesty’s Stationery Office (HMSO); 1991 3 DH. COMA Report 45. Weaning and the Weaning Diet. Report on Health and Social Subjects. HMSO, London; 1994 4 World Health Organisation (2001). The optimal duration of exclusive breastfeeding: report on an expert consultation. Geneva: WHO 5 Scientific Advisory Committee on Nutrition (2000). SACN Committee Meeting. September 2001 6 DH. Infant Feeding Recommendation. London: NB The Department of Health Infant Feeding Recommendations; 2003a.

7 Lanigan JA, Bishop J, Kimber AC, Morgan J. Systematic review concerning the age of introduction of complementary foods to the healthy full-term infant. Eur J Clin Nutr 2001; 55; 309-20 8 Butte NF, Lopez-Alarcon MG, Garza C (2002). Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. WHO, Geneva 9 World Health Organisation. Global strategy for infant and young child feeding. Geneva, Switzerland: World Health Organisation, 2003 10 ESPGHAN Committee on Nutrition. Complementary Feeding: A Commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2008; 46: 99-110 11 SACN. The SACN Subgroup on Maternal and Child Nutrition (SMCN): The Influence of maternal, fetal and child nutrition on the development of chronic disease in later life, 2011 12 SACN. Dietary Reference values for Energy. Scientific Advisory Committee on Nutrition; 2011 13 Royal College of Paediatrics and Child Health (2011). UK - WHO Growth Charts: early years. Available at: www.rcpch.ac.uk/growthcharts (Feb 2016) 14 British Dietetic Association (2013). Policy Statement. Complementary feeding: Introduction of solid food to an infant’s diet. Accessed online www.bda. uk.com/publications/professional/complementary_feeding_weaning (Feb 2016) 15 BLISS: Weaning your premature baby. 8th edition (2014). www.bliss.org.uk/Shop/weaning-your-premature-baby (Accessed Feb 2016).

16 The 1000 days campaign (2016). http://thousanddays.org/ (Accessed Feb 2016) 17 Bhutta ZA. Early nutrition and adult outcomes: Pieces of the puzzle. [Comment] Lancet, 382 (9891) (2013), pp 486-487 18 Barker DJ. Sir Richard Doll lecture: developmental origins of chronic disease. Public Health 2012; 126: 185-89 19 EAT (Enquiring About Tolerance) Study (in progress).www.eatstudy.co.uk/ (Accessed Feb 2016) 20 European Academy of Allergy and Clinical Immunology (2014). EAACI Food Allergy and Anaphylaxis Guidelines. Primary prevention of food allergy.

Allergy; 69: 590-601 21 Du Toit G et al (2015). Randomised trial of peanut consumption in infants at risk of peanut allergy. New England Journal of Medicine DOI: 10.1056/ NEJMoa1414850)

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clinical Photo A: Milk thickened with starch-based thickener

4. Thickened milk-products If you recommend milk (or fortified milk) to your clients, either for its nutritional value or to help them gain weight, you may want to modify this advice for clients who are on thickened fluid. I have attempted to thicken full-fat milk and fortified milk using every thickener on the market, and all starch-based thickeners give the mouthfeel of drinking curdled milk. Gum-based thickeners make the milk slightly less grainy, but I still found it borderline palatable. What seems to work the best is to make a smoothie by blending fortified milk + suitable fruit (e.g. no pips, skins or seeds) in a blender or smoothie maker. Blend until you get a smooth consistency, then add the gum-based thickener and blend for another 10 seconds. Smoothies are naturally thick and foamy and these qualities seem to mask any graininess from the gum-based thickener. Be aware that you sometimes need more thickener than what is directed on the tin to achieve the desired consistency. You may also need to let the drink sit for up to five minutes to achieve the desired consistency. For nutrition support clients who do not like thickened milk, additional calories can be obtained by adding thickener to pure fruit juice (or by using pre-thickened nutrition supplements).

5. Dehydration Patients on thickened fluid may struggle to meet their fluid requirements.5-8 In fact, a patient’s oral intake of thickened fluid can be as low as 32

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Photo B: Milk thickened with gum-based thickener

455mL per day.5 There are a variety of reasons for this, including being offered fewer drinks,6 flavour suppression, satiety,9 unpalatability and thickened drinks taking more time and effort to consume.7 Two studies have found that people with dysphagia tend to get the majority of their fluid from food with a high water content (as opposed to thickened drinks).6,8 Thick nourishing soups, pureed fruit, yoghurt and milk-based puddings are, therefore, recommended for this population.8 Other strategies which may help include increasing the choice and availability of thickened drinks, staff awareness and more assistance with drinking and toileting.9 Table 1 summarises the directions provided by each brand of thickener. From this I have calculated the number of calories and grams of fibre and carbohydrate that each thickener provides when preparing 1500ml of fluid to stages 1, 2 and 3. It is worth noting that the instructions for how to prepare thickened drinks are not consistent from one manufacturer to the next. All companies use different scoop sizes and recommend a different number of scoops per drink. Some companies give instructions per 100ml fluid, while others give instructions per 200ml. Some companies tell you to put the thickener in the cup before the fluid, other companies recommend the reverse. Even as a healthcare professional, I found this incredibly confusing. I do wonder how carers manage if they support multiple clients in a day, especially if each client is prescribed a different thickener. It

Table 1: Thickener comparison chart Thickener

Ingredients

Scoop size

Directions

Fibre content

Calorie content (of JUST the thickener)

Carbohydrate content (of JUST the thickener)

Multi-Thick™ (Abbott)

Modified maize starch, sulfur dioxide & sulphites.

1 scoop = 2.7 grams

Stage 1 - add 1.5 scoops to 100ml liquid

0 grams fibre/ scoop

9.9 kcal/scoop

2.5 grams CHO/scoop

Stage 2 - add 2.0 - 2.5 scoops to 100ml liquid Stage 3 - add 2.5-3.5 scoops to 100ml liquid

Nutilis™ (Nutricia)

Maltodextrin, modified maize starch (E1442), tara gum, xanthan gum & guar gum

1 scoop = 4 grams

Stage 1 - add 2-3 scoops to 200ml liquid Stage 2 - add 3-4 scoops to 200ml liquid Stage 3 - add 4-5 scoops to 200ml liquid

Nutilis™ Clear (Nutricia)

Dried glucose syrup, tara gum

1 scoop = 3 grams

Stage 1 - add 1 scoop to 200ml liquid Stage 2 - add 2 scoops to 200ml liquid Stage 3 - add 3 scoops to 200ml liquid

Resource Thicken Up™ Clear (Nestle)

Maltodextrin (corn, potato), xanthan gum & potassium chloride

1 scoop = 1.2 grams

Stage 1 - add 1 scoop to 100ml liquid Stage 2 - add 2 scoops to 100ml liquid Stage 3 - add 3 scoops to 100ml liquid

1500ml stage 1 fluid = 0 grams fibre 1500ml stage 2 fluid = 0 grams fibre 1500ml stage 3 fluid = 0 grams fibre

0.3 grams fibre/ scoop 1500ml stage 1 fluid = 4.5 - 6.8 grams fibre 1500ml stage 2 fluid = 6.8-9 grams fibre 1500ml stage 3 fluid = 9-11.3 grams fibre

0.84 grams fibre/scoop 1500ml stage 1 fluid = 6.3 grams fibre 1500ml stage 2 fluid = 12.6 grams fibre

1500ml stage 1 fluid = 223kcal 1500ml stage 2 fluid = 297-371 kcal 1500ml stage 3 fluid = 371520kcal

1500ml stage 1 fluid = 4.5 grams fibre 1500ml stage 2 fluid = 9 grams fibre 1500ml stage 3 fluid = 13.5 grams fibre

1500ml stage 2 fluid = 75-94 grams carbohydrate 1500ml stage 3 fluid = 94131 grams carbohydrate

14 kcal/scoop 150 ml stage 1 fluid = 210-315 kcal 1500ml stage 2 fluid = 315-420 kcal 1500ml stage 3 fluid = 420-525 kcal

8.7 kcal/scoop 1500ml stage 1 fluid = 65kcal 1500ml stage 2 fluid = 131kcal 1500ml stage 3 fluid = 196kcal

1500ml stage 3 fluid = 18.9 grams fibre

0.3 grams fibre/ scoop

1500ml stage 1 fluid = 56 grams carbohydrate

3.4 grams CHO/scoop 1500ml stage 1 fluid = 51-77 grams carbohydrate 1500ml stage 2 fluid = 77102 grams carbohydrate 1500ml stage 3 fluid = 102128 grams carbohydrate 1.73 grams CHO/scoop 1500ml stage 1 fluid = 13 grams carbohydrate 1500ml stage 2 fluid = 26 grams carbohydrate 1500ml stage 3 fluid = 39 grams carbohydrate

3.7kcal/scoop 1500ml stage 1 fluid = 56kcal 1500ml stage 2 fluid = 111kcal 1500ml stage 3 fluid = 167kcal

0.7 grams CHO/scoop 1500ml stage 1 fluid = 10.5 grams carbohydrate 1500ml stage 2 fluid = 21 grams carbohydrate 1500ml stage 3 fluid = 31.5 grams carbohydrate

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Thick & Easy™ (Fresenius Kabi)

Modified maize starch & maltodextrin

1 scoop = 4.5 grams

Stage 1 - add 1 scoop to 100ml liquid Stage 2 - add 1.5 scoops to 100ml liquid Stage 3 - add 2 scoops to 100ml liquid

Thick & Easy™ Clear (Fresenius Kabi)

Maltodextrin, xanthan gum, carrageenan, erythritol

1 scoop = 1.4 grams

Stage 1 - add 1 scoop to 100ml liquid Stage 2 - add 2 scoops to 100ml liquid Stage 3 - add 3 scoops to 100ml liquid

Thicken Aid™ (YJB Port Ltd)

Modified starch & maltodextrin

1 scoop = 4.5 grams

Stage 1 - add 1 scoop to 100ml liquid Stage 2 - add 1.5 scoops to 100ml liquid Stage 3 - add 2 scoops to 100ml liquid

is vital that dietitians work closely with speech and language therapists to lobby the thickener companies to come up with standardised, simple and clear instructions.

Continuous 72-hour trial: consuming thickened fluid

I have always sympathised with clients who need thickened fluid, but I also know that it is impossible to truly appreciate what someone is going through until you ‘walk a mile in their shoes’. To really gain an understanding of my clients’ experiences, I volunteered to consume thickened fluid for 72 hours (continuously).

One day, I drank stage 1 (syrup consistency),

0 grams fibre/ scoop 1500ml stage 1 fluid = 0 grams fibre 1500ml stage 2 fluid = 0 grams fibre

16.8kcal/scoop 1500ml stage 1 fluid = 252kcal 1500ml stage 2 fluid = 378kcal 1500ml stage 3 fluid = 504kcal

1500ml stage 3 fluid = 0 grams fibre

0.4 grams fibre/ scoop 1500ml stage 1 fluid = 6.5 grams fibre 1500ml stage 2 fluid = 12 grams fibre 1500ml stage 3 fluid = 18 grams fibre

0 grams fibre/ scoop 1500ml stage 1 fluid = 0 grams fibre 1500ml stage 2 fluid = 0 grams fibre 1500ml stage 3 fluid = 0 grams fibre

4.2 grams CHO/scoop 1500ml stage 1 fluid = 63 grams carbohydrate 1500ml stage 2 fluid = 94.5 grams carbohydrate 1500ml stage 3 fluid = 126 grams carbohydrate

4.08kcal/scoop 1500ml stage 1 fluid = 61.2kcal 1500ml stage 2 fluid = 122.4kcal 1500ml stage 3 fluid = 183.6kcal

1.2 grams CHO/scoop 1500ml stage 1 fluid = 18 grams carbohydrate 1500ml stage 2 fluid = 36 grams carbohydrate 1500ml stage 3 fluid = 54 grams carbohydrate

16.8kcal/scoop 1500ml stage 1 fluid = 252kcal 1500ml stage 2 fluid = 378kcal 1500ml stage 3 fluid = 504kcal

4.2 grams CHO/scoop 1500ml stage 1 fluid = 63 grams carbohydrate 1500ml stage 2 fluid = 94.5 grams carbohydrate 1500ml stage 3 fluid = 126 grams carbohydrate

the second day was stage 2 (custard consistency) and the third day was stage 3 (pudding consistency).

How much you like something has a lot to do with whether or not it matches your expectations.10 Obviously, consuming tea with a spoon did not match my previous experience or expectations. Consequently, I found the entire situation really, really disappointing. I now totally understand why people with dysphagia tend to prefer food with a high water content (compared to thickened drinks).11,12 You expect certain foods to be thick and creamy, you don’t expect your tea or water to be like this. www.NHDmag.com March 2016 - Issue 112

35

clinical

How much you like something has a lot to do with whether or not it matches

your expectations.

Obviously, consuming tea with a spoon did not match my previous experience or expectations.

I have experimented with almost every thickener on the market and I can honestly say that if I was put on a starch-based thickener, I would rather have a PEG. I tried it in milk, cordial and a fizzy drink, and everything tasted so stodgy and horrid that I couldn’t even drink one glass let alone meet my fluid requirements. Starch-based thickener added to milk also makes the drink look curdled - not pleasant! Gum-based thickeners were tolerable at stages 1 and 2, as long as the thickener was mixed in really well.

Getting little unexpected globs of thickener in your mouth does NOT make for a pleasant surprise! It actually turned my stomach so much a few times that I couldn’t finish what I was drinking.

If you have a client on thickened fluid, I urge you to consider the following: • Make sure all clients know that they have a choice of thickeners and that all thickeners have a slightly different taste So many of my clients believe that whatever they were given in hospital is the only thickener that exists. Speech and language therapists are sometimes very quick to discharge after they’ve made their eating and drinking recommendations, so it is often up to the dietitian to advocate on the patient’s behalf to get a different (and hopefully more palatable) thickener.

36

www.NHDmag.com March 2016 - Issue 112

• Check how the carers are preparing thickened drinks Lumps and globs of unthickened thickener in a drink are an automatic turn-off. I preferred to put the drink + thickener in a blender or smoothie maker for a few seconds to achieve the most even consistency. It made the end product a bit foamy, but foamy was infinitely better than lumpy.

• Be prepared When you require thickened fluid, everything has to be pre-planned. If I suddenly decided I wanted a sip of something cold, I’d have to go through the whole production of getting a glass + fluid + thickener + spoon/shaker… at which point, I generally decided it was such a hassle that I just wouldn’t bother. It occurred to me that it would have been smarter to make several bottles of thickened cordial all at once and store them in the fridge. That way they would have been ready whenever I wanted them.

• Offer mostly high-calorie thickened fluid Thickened drinks filled me up and made me feel a tiny bit sick. I’m not sure if this was due to the soluble fibre, the mental concentration involved in drinking thickened fluid or whether the thicker viscosity was somehow more satiating. Eating less meant that it was critical that I consumed high-calorie drinks. Fortunately, thickened pure fruit juice and thickened smoothies were my preferences (but only if they were made in a blender/smoothie maker).

Life’s little joys needn’t be hard to swallow Fresenius Kabi is supporting Nutrition and Hydration week 14th – 20th March 2016 Fresenius Kabi is supporting Nutrition and Hydration Week 14th - 20th March 2016 by providing dysphagia training to all carers and chefs that have residents with dysphagia that use Thick and Easy™ and Thick and Easy™ Clear.

The dysphagia training will help develop their key skills with managing dysphagia from mixing fluids correctly to providing them with easy, nutritious snacks and meals.

Fresenius Kabi provides a wide range of support to help patients with dysphagia, carers and HCPs to use Thick and Easy™ and Thick and Easy™ Clear correctly: www.dysphagia.org.uk – range of recipe ideas and tips MyDysphagia app - available FREE on the app store Nutrition Service helpline - free specialist advice Dysphagia Specialists - training support Contact us today on 01928 533 533 or visit www.fresenius-kabi.co.uk and find out how we can make safe and pleasurable mealtimes a reality.

www.fresenius-kabi.co.uk

CONDITIONS & DISORDERS

The dietetic management of Irritable Bowel Syndrome Ali Hutton Registered Dietitian, Juvela (Hero UK Ltd) Ali worked as a dietitian in the NHS for six years and is now a product manager for Juvela Gluten Free Foods.

She also works as a Freelance Dietitian at the Grosvenor Nuffield Hospital in Chester.

For full article references please email info@ networkhealth group.co.uk

Irritable Bowel Syndrome (IBS) is a functional bowel disorder in which abdominal discomfort or pain is associated with defaecation, or a change in bowel habit, and with features of disordered defaecation.1 It affects 10-20% of the UK population2 and is characterised by symptoms of abdominal pain or discomfort, constipation and/or diarrhoea, bloating and flatulence.3 In this article, Ali Hutton looks at the important role of the dietitian in IBS management.

Diagnosis of IBS is on the increase, which places a large financial burden on the NHS.4 It is recommended that referral be made to a dietitian for advice and treatment where diet is considered to be a major factor in a person’s symptoms.5 Also, it has been recognised that early referral to a dietitian may lead to a reduction in future costs of care for people with IBS.5 Increased involvement in the management of IBS may represent a good opportunity for dietitians for make their mark and defend their profession in an NHS that is under pressure to commission evidencebased and cost-effective services.6 A diagnosis of IBS should be considered only if the person has abdominal pain or discomfort that is either relieved by defaecation, or is associated with altered bowel frequency or stool form3 and accompanied by two of the following: altered stool passage, abdominal bloating, symptoms worsened by eating and mucus per rectum.1 In people who meet the IBS diagnostic criteria, a number of blood tests should be done to exclude other diagnoses and they should be assessed and clinically examined for ‘red flag’ indicators.3 Guidance and pathway

Although gut hypersensitivity, postinfective bowel-dysfunction and a disturbed colonic motility are considered to be possible causes 38

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of IBS, its exact aetiology is yet to be established. Because of this, the main aim of treatment tends to be the relief of the most predominant symptom(s). A multitude of treatment options may be considered, including lifestyle intervention, pharmacological treatments, hypnotherapy, physiotherapy, behavioural therapies and dietary manipulation. In 2015, the NICE Irritable bowel syndrome in adults guidance3 was updated and now recommends that, where diet is considered to be a major factor in a person’s symptoms and they are following general lifestyle/dietary advice, they should be referred to a dietitian for advice and treatment, including single food avoidance and exclusion diets.7 This is based on the assumption that, where people with IBS tend to alter their diet to alleviate symptoms of IBS, they often do so in a self-directed manner or with guidance from inadequately qualified nutritionists, which can lead to the exclusion of individual foods or complete food groups. The guideline recognises that this may lead to inadequate nutrient intakes and ultimately malnutrition.

The IBS Algorithm (Fig 1) from the British Dietetic Association’s (BDA) IBS guidelines8 has given dietitians an evidence-based chronological pathway for the dietary management of adults with IBS. The algorithm encourages the use of clinical assessment,

Figure 1: The IBS Algorithm taken from the BDA’s evidence-based guidelines for the dietary management of irritable bowel syndrome in adults8

alongside dietary and lifestyle factors, in a three-tiered management approach. First line advice includes evaluation of eating habits and lifestyle, consideration of a food intolerance and assessment of dietary fibre, high-fat foods, fluid, caffeine and alcohol intake. Second line advice includes consideration of the low FODMAP diet, which will be discussed in a little more detail here, as its success has increased the referral of patients with IBS to dietitians for advice and has given dietitians recognition as having an important role to play in the management of IBS. Third line advice involves elimination and empirical diets.

The low FODMAP diet

FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) are short chain carbohydrates, the ingestion of which is believed to increase the delivery of readily fermentable substrate and water to the distal small intestine and proximal colon, resulting in luminal distension and induction of functional gut symptoms.9 The

low FODMAP diet is based on the theory that restricting these fermentable carbohydrates leads to a reduction in symptoms.

Whilst the NICE irritable bowel syndrome in adults guidance3 gives advice around the balance of good health, dietary fibre, wheat and lactose intolerance, sorbitol, caffeine, prebiotics, probiotics and aloe vera, the aforementioned 2015 update7 considers the use of the low FODMAP diet in the dietary management of IBS in adults. The guideline now recommends that if a person’s IBS symptoms persist whilst following general lifestyle and dietary advice, they should be offered advice on further dietary management, including single food avoidance and exclusion diets (e.g. a low FODMAP diet).

Given the lack of evidence on the long-term adverse effects of following the low FODMAP diet, the potential harms of following the diet without dietetic support were considered by the NICE committee. Nutritional inadequacy or deficiency caused by inappropriate or blanket restriction without suitable food replacements www.NHDmag.com March 2016 - Issue 112

39

The importance of patient reports

and modification of faecal microbiota whilst following the low FODMAP diet, were recognised as potential harms. The guideline now recommends that, given the complex nature of the diet, it should only be undertaken under the advice of a healthcare professional with expertise in dietary management. In addition to this, the NICE Costing report for IBS5 recommends increasing the use of dietitian referrals for people where diet is considered to be a major factor in their IBS symptoms.

IBS management in primary care

The British Society of Gastroenterology (BSG) clinical commissioning report for IBS/ functional symptoms10 advises that up to 50% of patients who are diagnosed with IBS by their GP are referred to secondary care for endoscopy and other tests to eliminate more serious illness. This has a cost implication for an already over-stretched NHS. The report identifies a lack of dietary advice before referral to secondary care as a common failing here.

It suggests that IBS management in primary care could be improved and savings could be made in both time and money by increasing integration with dietitians.

This recognition from NICE and the BSG offers dietitians an ideal opportunity to promote and defend their profession in an NHS that needs to commission services that are effective and can potentially generate savings. But recognition is not simply enough and dietitians need to demonstrate that they can deliver an effective treatment for IBS that is cost-effective and evidence-based.

40

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As IBS remains a symptom-based condition that cannot yet be reliably diagnosed or monitored with biomarkers alone, the patient report is essential to determine the diagnosis, gauge overall disease severity, develop rational treatment plans and assess outcomes.11 The most commonly employed definition of clinically meaningful improvement in IBS has been a patient’s ‘yes or no’ report.12 Whilst these definitions are assumed to have face validity, empirical data is needed for each outcome measure to assess the clinical significance of different degrees of change from both the patient’s and the physician’s perspectives.12 Dietitians need to be able to identify and predict what the desired outcome of their intervention will be and to what extent this has been achieved from the viewpoint of both the dietitian and the recipient, both of whom can have quite different perspectives and expectations.13 Patients should not be given expectations of a ‘cure’.9 Also, it is important to explain that diet may not be the cause of their symptoms and, if this is the case, then other therapeutic approaches may be needed. Explaining this from the onset may help reduce disappointment when dietary changes do not help to relieve symptoms.

Conclusion

There is no widely adopted validated method for measuring IBS symptom outcomes in clinical and dietetic practice in primary and secondary care.14 The BDA Gastroenterology Specialist Group (GSG) formed a group in 2012 to develop such a tool, in line with the BDA Model for Dietetic Outcomes.13 The GSG has encouraged dietitians to get involved in development of this tool.14 In conclusion, increasing their involvement and expanding their role in the management of IBS represents an excellent opportunity for dietitians to promote and defend their practice in an environment where commissioning groups favour effective and financially viable services. In order to do this, they will need to continue to find innovative ways of proving their worth and develop outcome measures to demonstrate their effectiveness in the management of this chronic and increasingly common condition.

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CONDITIONS & DISORDERS

Nutrition in cystic fibrosis: requirements and recommendations Jacqui Lowden Paediatric Dietitian - Team Leader Critical Care, Therapy & Dietetics, RMCH Presently team leader for Critical Care and Burns, Jacqueline previously specialised in gastroenterology and cystic fibrosis.

Although her career to date has focused on the acute sector, Jacqueline has a great interest in paediatric public health.

For full article references please email info@ networkhealth group.co.uk

Cystic Fibrosis (CF) is the most common life-threatening genetic disorder in Caucasians, with one in 4,750 live births being affected.1 CF is defined by a gradual deterioration in lung function, intestinal malabsorption and resultantly, impaired nutritional status. As lung disease and nutritional status are closely related,2 both are strong predictors of morbidity and mortality.1,3,4 Jacqui Lowden examines the nutritional requirements.

Nutritional requirements in CF are well documented and variations exist between different guidelines. However, all of these guidelines are based on crude estimates.5,6 Table 1 summarises present dietary recommendations.

Due to the diversity amongst patients with CF, such as genotype, nutritional status, respiratory function, and existence of co-morbidities, it is becoming more and more difficult to recommend nutritional requirements for energy and protein that are allembracing.

WHAT AFFECTS ENERGY AND PROTEIN REQUIREMENTS IN CF?

Many factors contribute towards poor nutritional status in CF, but there are three main contributors: • increased energy expenditure, e.g. chest infections • increased energy losses, e.g. malabsorption • infection-related anorexia

A negative energy balance can occur, due to a combination of malabsorption and increased energy requirements secondary to chronic infections.8 A number of studies have also examined resting energy expenditure (REE) in CF. These studies have concluded that REE is consistently higher in CF individuals.5,8,9,10 One of the more recent studies11 compared Pancreatic Sufficient (PS) patients with Pancreatic Insufficient (PI) patients and demonstrated a strong negative correlation between REE and pulmonary function in the CF PI group, whilst the CF PS group did not reach statistical significance. They found a significant correlation between REE and lean body mass, supporting previous studies.12,13 They also found a significant correlation between REE and Shwachman clinical score. As the disease progresses, REE% increased as Shwachman score decreased.

Other factors which impact on REE are summarised in Table 2.

Table 1: Present dietary recommendations Reference

Recommendations

UK CF Trust

120-150% Estimated Energy Intake (EAR) 200% Required Nutrient Intake protein

European CF Society

Normal energy requirements in presence of good lung function >120% EAR for malnourished individuals

CF Foundation

110-120% energy measured against standards for healthy population No protein recommendations www.NHDmag.com March 2016 - Issue 112

43

CONDITIONS & disorders Table 2: Factors that impact on resting energy expenditure (REE) Factor

Studies

Impact

Genotype

Fried et al 199114 Richards et al 200115

No difference REE increased in class I, II, III

Disease severity

Dorlochter et al 200316

Increased REE associated with low Shwachman score

Lung function (FEV1)

Dorlochter et al 2002

Increased REE associated with low lung function

Gender

Allen et al 200318 Stallings et al 200519

Females greater REE compared to controls than males Increases in females post menarche

IV antibiotics

Beghin et al 200320

Increased REE post IVs, due to systematic inflammation causing an increase in REE

Cystic Fibrosis Related Diabetes (CFRD)

Ward et al 199921

Decreased REE when recovering from exercise , which is increased in CFRD

Exercise

Richards et al 200122

Increased REE associated increases energy cost of exercise

Nutritional status

Fuster et al 200723 Marin et al 200624

Increased REE associated with lean body mass

17

It has been suggested that patients with CF may need up to 200% of the recommended daily caloric intake. These recommendations can be difficult to achieve, however, due to a number of other reasons, such as gastro-oesophageal reflux, abdominal pain and behavioural eating difficulties.8,25 OTHER CONSIDERATIONS

Social deprivation A UK study examined the effect of social deprivation on clinical outcomes and the use of treatments in the UK CF population. Using the UK CF Registry, this longitudinal study found that children from the most deprived areas weighed less, had a lower BMI and were more likely to have chronic Pseudomonas aeruginosa infection and a lower %FEV1. After adjusting for disease severity, these children were more likely to receive intravenous antibiotics, nutritional treatments and less likely to receive inhaled antibiotic treatment, compared with children from the least deprived areas. In conclusion, children with CF from more disadvantaged areas had worse growth and lung function compared with children from more affluent areas.26 Drug therapy There has been a recent breakthrough in the drug treatment of CF with the advent of ‘precision medicines’, which target particular 44

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CF mutations. The first drug of this kind KALYDECO (ivacaftor) is a CF Transmembrane conductance Regulator (CFTR) potentiator. It is indicated for the treatment of CF in patients age two years and older who have certain mutations in the CFTR gene. A statistically significant gain in body weight has been seen in patients receiving KALYDECO (ivacaftor) compared to patients treated with placebo.27 KALYDECO is a systemic CFTR modulator, which may also affect CFTR function in the gastrointestinal epithelia. This may contribute to improved absorption of nutrients. However, the mechanisms whereby changes in CFTR function may result in weight gain are, as yet, not completely understood and are probably multifactorial.

ARE WE ACHIEVING ADEQUATE GROWTH IN CF?

Over the years, improvements have been achieved in clinical outcomes for patients with CF. However, recent UK data is demonstrating a levelling off of BMI (Table 3).

Charts 1 and 2 show the median BMI of children and adults with CF in the UK. This data demonstrates that optimal growth and weight gain is still not being achieved and maintained.

The targets of 50% median BMI percentile for children and BMI of 23 for adult males and 22 for adult females have been chosen as they have demonstrated better lung function at these levels.28

Table 3: UK CF Trust Registry data 2007

2008

2009

2010

2011

2012

21.7

21.7

21.7

21.4

22

22

53.3

51.7

51.1

52.2

53.8

52.7

Median BMI kg/m2 Adults Median BMI centile children </= 17 years

Chart 1: The median Body Mass Index (BMI) percentiles in children and young people (<20 years) with CF (CF Trust Registry Report 2014)

Chart 2: The median BMI of adults with CF aged 20 and over in relation to the target BMI for a healthy adult; 22 for women and 23 for men (CF Trust Registry Report 2014)

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45

the effects of behavioural intervention and oral supplementation are not sufficiently consistent at present. Additionally, enteral tube feeding is especially effective at improving the nutritional status in malnourished patients and slowing down further pulmonary function decline.29

THE WAY FORWARD

Nutritional strategies Dietary fortification, the use of nutritional supplements, maximising absorption, behavioural interventions and tube feeding are all strategies that have been employed to aid weight gain and growth in CF. Table 4 shows a breakdown of nutritional therapy data from the UK Cystic Fibrosis Registry 2014 .There is, however, a lack of good quality studies to assess the effectiveness of some of these strategies.

A recent systematic review has assessed the literature published after 1997, describing the effectiveness of nutritional interventions in patients with CF. Seventeen research articles were reviewed, focusing on behavioural interventions (n=6), oral supplementation (n=4) and enteral tube feeding (n=7). The latter intervention was universally successful at promoting weight gain. One behavioural study and two oral supplementation studies also reported significant weight gain.

The review concluded that enteral tube feeding is effective to improve nutritional status, while

Adherence Non-adherence to treatments has always been a major challenge in CF, but data on the prevalence of non-adherence is limited. A recent systematic review concluded that methods on how to measure adherence are lacking and the quality of studies addressing adherence in CF is inadequate. Studies that use self-reported measures resulted in higher adherence scores than those that used objective measures. Due to these limitations, therefore, the prevalence of non-adherence remains unclear. The systematic review also concluded that, although adherence to a treatment program for CF is generally low, it also varies hugely depending on the type of treatment. The data, albeit limited, has indicated that nutritional therapy is at the lower end of adherence at 22% compared to 130% for oral antibiotics.30 CONCLUSION

With the increasing diversity amongst patients with CF, it is essential that each patient’s nutritional status is monitored closely and individually assessed. Any changes made to their nutritional management will require to be monitored and adjusted, depending on outcome.

A poor nutritional status can be reversed, unlike loss of pulmonary function. If we are to reverse this recent levelling off of nutritional status, it is crucial, that as dietitians, we care able to introduce more effective interventions individually tailored to our patients’ needs.

Table 4: a breakdown of nutritional therapy data from the UK Cystic Fibrosis Registry 2014

Any supplemental feeding; n (%)

Overall (n=9432)

<16 years (n=3840)

≥16 years (5592)

3214 (34.1)

857 (22.3)

2136 (38.2)

Nasogastric tube

114 (1.2)

12 (0.3)

102 (1.3)

Gastrostomy tube/Button

572 (6.1)

221 (5.8)

351 (6.3)

6 (0.1)

0

6

2

1

1

Jejunal TPN

UK Cystic Fibrosis Registry 2014. Annual Data Report Published August 2015

46

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CONDITIONS & DISORDERS

Ehlers-Danlos/hypermobility syndrome: can diet help with symptoms?

Janet Dennis Freelance and Locum Dietitian Janet has a professional interest in coeliac disease, allergy and intolerance, Ehlers-Danlos syndrome and care of the elderly.

For full article references please email info@ networkhealth group.co.uk

As a sufferer of Ehlers-Danlos syndrome - hypermobility type 3, Janet Dennis was finally diagnosed after 30 years of various symptoms. Both of her children have inherited the same genetic type of this disorder. In this article, Janet explains the symptoms, the risks and dietary management of Ehlers-Danlos.

Ehlers-Danlos syndrome (EDS) is a group of genetically inherited disorders of the connective tissue or collagen, which is made out of a protein that provides support to skin, tendons, ligaments, blood vessels and bones and makes up one third of all the protein used in the body. People with EDS inherit errors in their genetic makeup, possibly involving more than one gene, which makes their collagen unusually weak or fragile. Although there are now at least six types of EDS which have been identified, they have many features in common such as joint hypermobility or unstable joints, stretchy skin and tissue fragility which can cause profound biomechanical changes and instability in joints and weakness in muscles leading to pain and injury. This can lead sufferers to seek medical attention for arthritis or arthralgia and the possible requirement for a referral to a pain management clinic.

Other issues that may be seen in these patients include dysmobility of the gut and oesophagus, gastroparesis, possible intestinal failure and IBS symptoms, some of which can lead to progressive disability without treatment.1 How common is Ehlers-Danlos disorder?

The first known description for hypermobility was in the 4th century BC describing atony/hyperlaxity of the elbow and shoulder joints found in warriors from India. These warriors were unable to shoot arrows against the enemy effectively due to their lax joints and were, therefore, defeated against the

enemy. Joint hypermobility and its related disorders were not fully recognised officially as a clinical condition until the 20th century.10 It used to be thought that this was a very rare disorder, but research into this complex condition suggests that, out of a recent study of 12,800 participants, 3% had this genetic disorder, so it is not quite as rare as the medical professionals first anticipated. It is often an underdiagnosed, not understood and poorly managed condition.

Symptoms

There is a range of possible symptoms seen across the spectrum of the disorder with pain being the most common symptom. Individuals with this condition may have some or many of the following: • Joint hypermobility • Dislocations/subluxations • Impaired proprioception and alteration of musculoskeletal reflex • Joint pain/fatigue • Easy to bruise/scar • Asthma • Gastrointestinal symptoms/reflux/ swallowing issues/food intolerance • POTS (postural Orthostatic Tachycardia Syndrome) can cause a fast heart rate, dizziness and fainting when standing • Mitral valve prolapse - a heart valve abnormality • Partial or complete failure of local anaesthesia • Varicose veins/prolapses and hernias /urinary incontinence www.NHDmag.com March 2016 - Issue 112

47

CONDITIONS & disorders • • • • • •

Osteopenia (weakened bones) Curvature of the spine Poor wound healing Premature osteoarthritis Gum and teeth problems In the vascular type, the walls of blood vessels can rupture easily proving to be fatal

Dietary management of Ehlers-Danlos syndrome

Currently, there are no evidence-based guidelines for the nutritional management of a patient with EDS and symptoms vary widely. However, the involvement of nutrition and the gut is becoming more widely recognised, including poor motility, poor absorption and poor eating habits due to pain, along with the belief that dietary restriction helps with the symptoms. Further research is needed and symptom management is continuing to be updated as more information is discovered about this condition.

A patient may present with one or several of the above symptoms listed as a hospital admission or in an outpatient’s clinic. Exclusion or allergy diets are frequently followed with patients eliminating wheat, dairy products and sugar, believing that this helps control fatigue as well as gut symptoms such as bloating and constipation. Currently there is no conclusive evidence to support the benefits of excluding these foods, but many sufferers of EDS report multiple food intolerances, so they would need to be advised on a well-balanced diet, restricting intake of foods if there is evidence of benefits and nutritional adequacy assessed by a dietitian. The importance of a well-balanced diet based on the Eatwell plate, including adequate amounts of calcium and vitamin D (DOH/Food Standards Agency), providing a wide range of essential nutrients, should be reinforced,2 which should include good quality sources of protein, such as lean meat, poultry, fish, nuts and beans to provide optimum nutrients for soft tissue repair.

Speech and language therapy

A patient with EDS may need to be referred to a speech and language therapist as they may have delayed speech problems from a younger age, a weaker swallow and struggle with swallowing denser foods such as apples, potatoes, bread and boiled eggs caused by weaker muscles. Support and guidance may be 48

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required with managing their swallow correctly as well as further assessment if their swallow is compromised further.

Food preparation/cooking

Difficulties with buying, preparing and eating food should not be underestimated with joint conditions.

The patient with EDS may find it difficult to use their hands to peel and chop and cut food, it may be difficult for them to stand or sit for long periods, which may have an adverse effect on appetite.2 They may also be suffering from extreme fatigue, so it is essential for them to plan balanced meals, which are very simple to prepare, or pre-frozen meals are a good alternative. Advice from a dietitian can be useful on preparing easy and quick meals that are nutritional balanced. An occupational therapist may help with advice on using suitable cutlery that maybe easier to hold as well as implements and equipment, which can enable the patient to prepare more of their own food with less pain Management of Postural Orthostatic Tachycardia syndrome (POTS)/Dysautonomia

Dysautonomia is a description of different medical conditions that cause malfunction of the autonomic nervous system. Postural Orthostatic Tachycardia syndrome, or (POTS) for short, is one of the medical conditions identified under the umbrella term of Dysautonomia. It causes a range of possible symptoms in the patient, such as low blood pressure, fainting, dizziness, palpitations and fatigue when the patient stands.

Aim of treatment is to reduce symptoms by increasing fluid volume and salt intake. Best advice for a patient is to have a drink before getting out of bed in the morning and eat small meals and avoid alcohol. Exercise has also been shown to be beneficial. Those with severe symptoms should be referred to a specialised POTS or cardiology clinic.11 Gastro-intestinal symptoms

Attention to hydration, exercise, sleep and regular mealtimes may need reinforcing. There may also be a need to follow current recommendations for IBS and probiotics may be useful with diarrhoea, constipation and bloating and abdominal pain. Advice may be needed for coping with reflux. Motility disorder is

very common in these patients too. The FODMAPS diet may be useful in some patients, as some food is thought to ferment if it has a slow transit through the gut. If still severely symptomatic, the patient will need referral to a GI specialist.

Weight management

It is important that people with EDS try to maintain a healthy weight, as any excess weight can exacerbate joint pain and stiffness and further restrict mobility and weight bearing. Exercise can be very difficult at times due to injury, dislocations, pain and fatigue. It is also important for the patient not to become underweight, as this can make maintaining muscle strength more difficult.

Omega-3

There may be benefits from the anti-inflammatory effects of omega-3 for painful or inflamed joints.2 Rich natural sources include sardines, salmon, mackerel and pilchards.3 Osteoporosis

Some studies have examined patients with joint hypermobility and have discovered that patients with Ehlers-Danlos/hypermobility have a lower bone mineral density, as hypermobile joints increase the risk for low bone mass and fractures.

In one particular study, hypermobile joints were shown to increase the risk of low bone mass by 1.8 times.4 This could be due to a number of factors such as reluctance to stand, walk or exercise due to pain levels and injury, immobility, or due to food restriction due to gut disturbances such as chronic constipation or even coeliac disease.8 Coeliac disease symptoms

In Italy, up to 1% of the population has been found to have coeliac disease. A recent study suggests that, in Italy, coeliac disease is 10/20 times more common in patients with confirmed EDS compared to the rest of the population. It is still unclear from this research how an autoimmune condition such as coeliac disease is apparently linked to the genetic condition of EDS. Further studies are needed to confirm the evidence in different geographical areas of the world.6 In clinical practice, a patient can present with chronic fatigue, bloating, constipation, nausea, diarrhoea and abdominal pain, some or all of

these symptoms can be identified in EDS, as well as coeliac disease. No systematic study has yet been undertaken.5 These preliminary studies have shown an increased rate of coeliac disease in EDS.7 Coeliac disease testing may be useful to rule it out as a possible cause of symptoms.

Living with hypermobility

Going to work or looking after a family can be difficult, as life gets more painful. Just everyday repetitive activities, such as walking, using a phone or a computer, sitting, going shopping and getting dressed, can become difficult to manage and cope with. The patient may refuse to participate in family activities because of pain and fatigue. In some patients, even being touched can be painful and some can prefer to sleep alone rather than risk pain and sleeplessness from sleeping with a partner. Activity can be restricted, leading to further pain, fatigue and injury and a general deconditioning of muscles and joints become apparent. A multi systemic approach is needed to deal with the management of various symptoms.

Health professionals need to recognise the impact that this degenerating, deteriorating condition has on every aspect of a patient’s life, as well as on their families and help to educate, empower and support the patient.

Encouraging self-management should be the aim in order for strength and independent function to be the ultimate goal. A well balanced diet, regular exercise and activity and getting enough sleep is recommended.

It is recognised that periods of inactivity exacerbate symptoms, but activity needs to be controlled to prevent further pain, injury and fatigue.

Patients often complain that they have not been listened to and many have lived without a diagnosis for years. The health professional needs to provide education and support, as getting a diagnosis can be difficult and referral to a specialist can take many years. There is no cure for this condition, treatment includes managing symptoms, stabilising joints, getting appropriate support, as well as avoiding complications maintaining a healthy weight and a balanced diet.9 Research into this condition remains limited, but there is a charity that helps to raise awareness of the condition and give advice and support to sufferers. This is run by people who suffer from the same condition: The Hypermobility Association HMSA Helpline: 03330 116 388. Visit their website: www.hypermobility.org www.NHDmag.com March 2016 - Issue 112

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WEIGHT Management

I have changed my mind… (about Gwyneth Paltrow)!

Ursula Arens Writer; Nutrition & Dietetics Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company.

She was also a nutrition scientist at the British Nutrition Foundation for seven years.

Ursula helps guide the NHD features agenda as well as contributing features and reviews

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Last Christmas, Santa gave me books again.

Totally happy of course, because books are my favourite thing in the world. The best book was a compilation of thoughts from 80 scientists on the topic of, ‘What have you changed your mind about?’1 Two of the contributors prompted my change of mind about celebrity contributions to nutrition science discussions. A jumble of thoughts snapped into new focus, and this was now the contribution I would have made, had I been asked, to Brockman’s compilation of U-turns.

Charles Seife is a Professor of Journalism at New York University and a writer for Science magazine. He battled with the differences between decision-making in science institutions and in democratic societies. Previous scientific creations in the United States were developments from the effetes and elites of old-Europe, and often clashed with the meritocratic ideals of youngrebel US. Even today, these cultures clash: in a democratic system, ideas are protected, and free dissemination is the most essential structure for group decision-making. In science, it is the opposite: being open-minded is not the thing, it is being right and being able to argue and prove it. The science agenda to disprove or discredit (wrong) ideas clashes with the democratic drives to tolerate and protect them.

Because science and democratic communications operate on different machinery, there will always be some muddle when these two systems meet in the media.

The next writer with a peppermintfresh perspective is the neuroscientist Marco Iacoboni, from the Brain

www.NHDmag.com March 2016 - Issue 112

Mapping Centre at the University of California. He ponders why hocuspocus and supernatural thinking seems to hold so much public headspace, despite the many factfilled and logical opposite positions presented by earnest and very learned scientists. Professor Iacoboni observes that this is because science plays such a marginal role in public discourse: for example, there were no science books in top 100 lists issued by the high-brow opinion leaders, The New York Times, The Economist or New Yorker magazine.

This is because scientists self-confine themselves within narrow boundaries of topic and do not allow themselves comment towards more general and mixed-up discussions. The hypothesisdriven format of enquiry often inhibits more broad-based descriptive studies on issues described as ‘real-world’ and of much greater interest to general populations. Professor Iacoboni’s final critique is that scientific phenomena are examined from detached and atemporal perspectives, in order to generate new rules and laws. However here-and-now issues are what most

million glucose measurement data were then analysed. Post-prandial glycaemic responses were found to be correlated with BMIs, with glycated haemoglobins, with wake-up glucose measures and with age. Data for the same person having the same meal were consistent, but there was high interpersonal variability to same meals. For example, mean glucose elevation from bread was 44mg/dl/h, but lower and upper decile values spanned 15-79mh/dl/h. To some foods, opposite responses were observed in a few individuals, and the foods sushi in comparison to ice cream were mentioned as an example.

David Zeevi and colleagues3 managed to persuade 800 healthy and free-living adults to be connected to continuous subcutaneous glucose sensors, which measured blood glucose levels every five minutes, for a week.

people want and relate to. Scientists need to loosen up and share more within public discussions: science is actually so exciting and vibrant, that people will become naturally engaged and will eventually become more reluctant to believe unprovable things.

Then, by chance, I read a feature by The Times newspaper science writer, Oliver Moody.2 He was hoping for The final part of the research was to computer-plan more progress on science-based individual diets for 26 willing subjects, with a view to discussions in the media. In the more modest post-prandial glycaemia. section entitled ‘Square Meals and Round Pegs’, he pulled out the Hollywood actress Gwyneth Paltrow from the long list of A-list celebrities promoting diets based on F-grade science. Counter to the views of The computer scientists at the Weizmann Ms Paltrow, Mr Moody explained that it had Institute then pooled 137 features, including all become increasingly apparent that some foods aspects of food contents and timings, to develop a could affect people in very different ways machine-learning algorithm to predict glycaemic depending on the bacteria in their guts and that responses. Total carbohydrate contents of foods the Weizmann Institute of Science in Israel had provided modest but statistically significant suggested that basic ingredients such as butter correlations to subsequent blood glucose levels: it and tomatoes could be excellent for some, but would have been very astonishing if this had not anathema to others. been the case. The researchers later suggest that while Such an unfortunate own-goal. Had Ms dietary carbohydrates translate into blood glucose Paltrow asserted that food responses were responses in nearly all people, up to 5% of people not variable? The much-publicised Weizmann appear to be carbohydrate ‘insensitive’ and their Institute research was about the prediction of responses are skewed and variable and so added blood glucose responses to different foods: unpredictability to the developed algorithms. neither butter nor tomatoes were mentioned, Could differences in microbiome comperhaps not least because butter does not positions be one explanation for some glycaemicdirectly affect blood glucose levels. So what did response inconsistencies observed?

The the research from the Weizmann Institute of researchers observe 20 statistically significant Science actually demonstrate? correlations between some aspect of gut flora and David Zeevi and colleagues3 managed to higher or lower glycaemic responses: for example persuade 800 healthy and free-living adults Eubacterium rectale was mostly beneficial, whereas to be connected to continuous subcutaneous Bacteroides spp were mostly adverse as correlates. glucose sensors, which measured blood glucose Some of the myriad variations of microbiome levels every five minutes, for a week. And also may show predictive patterns with post-prandial gathered of course, were diary-reports of all glycaemic responses, and the researchers conclude foods and activities data. The subsequent 1.5 that their results offer pointers for future research. www.NHDmag.com March 2016 - Issue 112

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WEIGHT management

So my change-of-mind in 2016 is to be completely chilled and mellow about any dietary pronouncements made by Gwyneth Paltrow

Andrea Raffin at www.andrearaffin.com

But data from this research linking gut flora as causal to subsequent glycaemic responses was feather-light and tissue-thin. They conclude that there are multiple and diverse factors linked to post-prandial glucose responses that were not directly related to meal content, which supports current views that glycaemic data from fasted states cannot fully predict glycaemia in mixed meal real-life scenarios.

The final part of the research was to computer-plan individual diets for 26 willing subjects, with a view to more modest postprandial glycaemia. Results showed these hoped-for effects in most (80%) of the good or bad diets, and from this they predict a more robust basis for personalisation of dietary advice in the future.

Conclusions from the study were that, although carbohydrate is still the strongest predictor of post-prandial glycaemic response, other non-marker-meal correlates include timing and contents of previous meals, time since sleep, proximity to exercise, and lastly, possibly the many assorted microbiome factors. The few subjects who were outliers in relation to glycaemic responses were not linked by opposite reactions to butter or

tomatoes, but this may be the single message left to seed and grow in the minds of readers of The Times.

So, a science journalist and a beautiful film star both muddle the messages and contribute to public confusion and scepticism about the boring-old healthy eating messages issued by health professionals. But there is a difference.

Celebrities are not claiming to contribute to science debate; rather they are answering the question put to them all the time, “You are so slim and beautiful/handsome, how do you do it?” Of course they cannot be blamed for sharing, perhaps on commercially funded platforms, their own health and beauty secrets.

I too would be willing to share my (ignorant) views on cinematic topics of dolly shots or mid-lighting, but no one from Hollywood Reporter has asked me, or is likely to. But for scientists to be in uproar about the garbled logics of film stars suggests unnecessary jealousy and defensiveness. Of course celebrity comments have influence, but their currency of authority is short-lived and flimsy, in contrast to the outputs of science experts (such as dietitians). But it does add responsibility to those making expert comment in the media to check primary information sources, as so much media comment is based on previous media comment.

So my change-of-mind in 2016 is to be completely chilled and mellow about any dietary pronouncements made by Gwyneth Paltrow sorry, about any previous critiques. But being half as critical of celebrities means being doubly critical of those with science-hats being muddled - being expert means being responsible.

References 1 Brockman J (ed) (2014). What have you changed your mind about? Today’s leading minds rethink everything. Edge Foundation Inc, Harper Collins 2 Moody O (Jan 2, 2016). Scientists hoping 2016 will be year of progress. The Times, News, page 35 3 Zeevi D, Korem T, Zmora N et al (2015). Personalized Nutrition by Prediction of Glycaemic Responses. Cell, 163, 5, 1079-1094

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Web watch

web watch Online resources and useful updates.

Visit www.NHDmag.com for full listings.

First Steps Nutrition Trust publishes three new infant milk guides Three newly updated guides to infant milks in the UK are available to download from this charitable organisation’s website. Published in February 2016, they focus on over-thecounter infant milks for sale in the UK. 1. Infant milks in the UK - A practical guide for healthcare professionals providing an

excellent overview of all infant milks available to buy over the counter in the UK. It is supported by UNICEF Baby Friendly, The Baby Feeding Law Group, The Royal College of Midwives, The Royal College of Paediatrics and Child Health and many others. Public Health Wales, The Scottish Government and The Public Health Agency Northern Ireland helped to fund this work.

2. Infant milk composition available in the report above as

section 5, but also available as a separate downloadable report.

3. Cost of infant milks marketed in the UK A summary of all of the infant milks for sale in the UK. A useful way to compare value-for-money and suitability of some infant formulas depending on their presentation and any nutritional claims attached to them.

All available to download for free at: www.firststepsnutrition. org/newpages/Infants/infant_ feeding_infant_milks_UK.html

RECENT NICE GUIDANCE AND QUALITY STANDARDS lifestyle weight management gastro-oesophageal reflux disease programmes required for adults (GORD) in children and young This quality standard covers the who are overweight or obese. people under 18. Published management of diabetes and the Depending on local definitions, Jan 2016: www.nice.org.uk/ possible complications that all these are often tier 2 lifestyle guidance/QS112 females of childbearing age may interventions, including a face when planning a pregnancy variety of weight management Guidance on the ‘Care of or during their pregnancy. programmes, courses or dying adults in the last days Additional or different care clubs, which are important of life’. options which should be offered in the management of this Published in December to women with diabetes and patient group. Tier 3 specialist 2016 this guideline provides their newborn babies, are also management or tier 4 bariatric recommendations for the clinical covered by this quality standard. surgery interventions are not care of adults (18 years and over) Published Jan 2016: www.nice. covered in this quality standard. who are dying during the last 2 to org.uk/guidance/qs109 Published Jan 2016: http://www.

3 days of life. Aiming to improve nice.org.uk/guidance/qs111 end of life care for people in their Quality Standard for last days of life, the guideline ‘Obesity in adults: Guidance on ‘Gastrocovers how to manage common prevention and lifestyle oesophageal reflux in children symptoms without causing weight management and young people’ unacceptable side effects and Covering the management of maintain hydration in the last programmes’ Covering the prevention of adults gastro-oesophageal reflux (GOR) days of life.Find full details (aged 18 and over) becoming symptoms. Also recognising, at http://www.nice.org.uk/ overweight or obese and the diagnosing and managing guidance/ng31

Quality Standard for Diabetes in Pregnancy

www.NHDmag.com March 2016 - Issue 112

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web watch World Health Organisation Ending Childhood Obesity (ECHO) report On the 25th January 2016 The Commission on Ending Childhood Obesity (ECHO) presented its final report to the WHO DirectorGeneral. The report is the conclusion of a two-year process to address the rapidly increased levels of global childhood obesity and children who are overweight.

The ECHO report details a range of recommendations for governments, which aim to reverse the current rising trend of children under the age of 5 years becoming overweight and obese. Please see pg 7 for more on this report or visit www.who. int/end-childhood-obesity/finalreport/en/

New Juvela web pages to support gluten-free living for children and students Two new children’s pages offer information, games and recipes in two categories (Juvela Infants for children up to six years old and Juvela Juniors for children over seven years of age). For students who are starting college or moving away to university the new pages offer general support for independent gluten-free living, tips and ideas for managing a glutenfree diet on a budget, as well as avoiding contamination when using shared living spaces. All age groups can join ‘Juvela Club’ to receive free regular updates and newsletters, share experiences, plan meals and save favourite gluten-free recipes.

Find full details at www.juvela.co.uk/ kids-home/ or www.juvela.co.uk/ students/

Action on Sugar: excessive amounts of sugar in high street hot drinks In recent weeks the huge amount of sugar found in high street hot drinks has hit the national news.

Action on Sugar has released data to show that high street hot drinks chains are serving many drinks with between 13 and 25 teaspoons of sugar per drink. Action on Sugar is a registered charity and works with specialists concerned with sugar and its effects on health.

Aiming to highlight the harmful effects of excessive sugar intakes, Action on Sugar is lobbying the food industry and Government to bring about a reduction in the amount of sugar in processed foods. www.actiononsugar.org/

dieteticJOBS.co.uk The UK’s largest dietetic jobsite since 2009

CAREER

*5$'8$7(

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We urgently require dietitians for immediate vacancies s

• Quarter page to full page • Premier & Universal placement job listings • NHD website, NH-eNews and NHD Magazine placements To place an ad or discuss your requirements please call

0845 450 2125 (local rate) 54

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To find out your options call or email Freephone: 0800 032 0454 Registration@pjlocums.co.uk

s s s

PJ Locums is an NHS Buying Solutions framework approved supplier for allied health Our aim is to find you the right person and the right job We offer inpatient and community UK & NI coverage Competitive rates

www.pjlocums.co.uk NHDmag.com October 2015 - Issue 108

49

A DAY IN THE LIFE OF . . .

A DIETITIAN NAVIGATING THE WORLD OF CHARITY Isobel Bandurek Registered dietitian (HCPC), Centrepoint, London

Charity work and volunteering have always been passions of mine and at the beginning of 2015, I was lucky enough to land my first paid role in the charity sector: working as a Healthy Living Advisor for Centrepoint, the largest charity working with homeless young people in the UK.1 Additionally, I volunteer for Ashanti Development, a small development charity working in rural Ghana.2

Isobel has worked in community and acute NHS dietetic roles and has recently moved into the world of charity.

She has a particular interest in health promotion in both developed and developing countries.

With Centrepoint, I enjoy a varied and challenging dietetic caseload.

However, my job extends beyond what might be considered a traditional dietetic role, with client-based work involving support around sexual health and physical activity. Set within a multidisciplinary team, I am fortunate to work amongst psychotherapists, substance misuse workers, dual diagnosis practitioners and healthy relationships workers. My role demands a variety of activities, including 1:1 sessions, group workshops, risk and vulnerability panel discussions, case reviews, external partnership building, staff consultancy and bids for funding.

One thing I have particularly thrived on is how no two days are the same. This stems from the variety of tasks that the job requires, and also the inherently kaleidoscopic nature of the client group. Even ‘basic’ dietetic referrals around healthy eating are overlaid with complex social, financial and other health issues; for example, 42% of homeless young people report symptoms of poor mental health.3 As an example, allow me to take you through last Monday…

This morning’s task focuses on some ongoing 1:1 work with Nina*, a 19-year-old young woman who is six months pregnant. Clients are initially offered a block of six sessions over six weeks, lasting one hour each; however, in line with the team’s client-centred values, we have adopted a more

flexible approach accommodating her midwife appointments, social services meetings and other external support. This is our eighth session together and, so far, we have worked on food safety during pregnancy, appropriate nutrition support (Nina’s preconception BMI indicated high risk of malnutrition4), effective budgeting for healthy eating and increased confidence in the kitchen.

Our practical session today centres on cooking a sausage and bean stew while discussing the health benefits of pulses. It’s great to see her realise how cost-effective cooking with beans can be! Working together so frequently over a block of sessions offers the opportunity to develop a therapeutic relationship that facilitates disclosures around other areas of clients’ lives. For example, Nina and I have regularly discussed her low mood and I have supported her in accessing counselling within our multidisciplinary team.

Engagement and change

After clearing up and trying Nina’s stew (delicious by the way!), I hotfoot it across London to deliver a presentation to a group of prospective funders. Far from unusual, I am regularly based out of two or more hubs each day (and I have now developed the additional skill of knowing the Tube Map off by heart). The potential donors have been treated to talks from a variety of Centrepoint stakeholders, including some of the young people www.NHDmag.com March 2016 - Issue 112

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A day in the life of . . .

Ashanti Development

we support. My task is to portray how the team seeks, and succeeds, to reduce the health inequalities experienced by homeless young people. I have chosen to illustrate this by my work with Daniel*, a 20-year-old resident who, amongst many challenges, is trying to manage Type 1 diabetes mellitus. In Daniel’s situation, we have supported him to increase engagement with statutory services while concurrently supporting him at his hostel to reflect on his health behaviours and initiate the process of change.5 The funders appear interested, but the clincher is when I produce some samples of the dishes Daniel and I have cooked together for them to try!

This evening, I am off to another hostel to deliver a group workshop; these provide the opportunity for young people to interact with each other through cooking, engage with health messages and also experience the important social side of food. This week’s theme is ‘salt’ and I am excited to be co-facilitating with a colleague. Once all the dishes are ready (and the noise has died down a little) we tuck in. As we eat together, I ask, “So how much salt is in our dinner?” They are surprised to realise that none has been added throughout the cooking process and a guided discussion ensues around the role of salt in the body and key dietary sources.

1 2 3 4 5

Each month I devote several evenings to volunteering with Ashanti Development.

Their mission is to relieve poverty and improve health in the Ashanti region of Ghana through sustainable projects, including access to a safe water supply. At present, my contribution is primarily focused on fundraising events and generating financial capacity to fund new projects. An event of particular interest is ‘A Taste of Ghana’, which is held each summer: guests are invited to taste a plethora of Ghanaian dishes (all thanks to Ashanti Development’s founder Martha Boadu) in an appropriately laid-back, Ghanaian atmosphere of great music and great company.

Since starting my work with them, their scope in health improvement has widened to include the nutritional status of local people, which is well documented to be inextricably linked to poverty and future development.6 Ashanti Development currently has a programme for identification of malnutrition in infants, which has the potential for great growth (if you’ll excuse the pun!). Talks with key NHS and academic partners have been set in motion, further highlighting the potential - and valuable - role of a dietitian in a wide spectrum of sectors. Personally, I am hoping to visit the region later this year with a view to setting up a sustainable project based on local nutritional needs.

As a dietitian in the charity sector, I enjoy the flexibility, autonomy and tremendous variety it brings: from 1:1 sessions with homeless young people and networking with prospective donors, to conceptualising public health nutrition interventions in West Africa. I am grateful for the never-ending supply of challenge, drama and technical interest that I experience daily. My work is rarely a walk in the park - when is dietetic work ever! But then, feeling tired and satisfied each evening seldom gets old. *Please note that names have been changed to maintain confidentiality.

Centrepoint UK: http://centrepoint.org.uk/ Ashanti Development: http://ashantidevelopment.org/ Centrepoint (2015). Toxic Mix: The Health Needs of Homeless Young People. Accessed via: http://centrepoint.org.uk/ British Association for Parenteral and Enteral Nutrition (2003). Malnutrition Universal Screening Tool. Accessed via: www.bapen.org.uk Prochaska JO, DiClemente CC and Norcross JC (1998). Stages of Change: Prescriptive Guidelines for Behavioural Medicine and Psychotherapy. GP Koocher, JC Norcross and SS Hill III (Eds), Psychologists’ Desk Reference. New York, Oxford: Oxford University Press 6 Peña M and Bacallao J (2002). Malnutrition and Poverty. Annual Review of Nutrition. Vol 22: 241-253 (Volume publication date July 2002). DOI: 10.1146/annurev nutr 22.120701.141104

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CAREER

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

DIETITIANS WANTED - BUPA NUTRITION DEPARTMENT - LONDON Located in the heart of Kensington, Bupa Cromwell Hospital is committed to providing the highest quality healthcare. We deliver an unparalleled patient experience, tailored to cultural needs and are continuously improving best practice. The Nutrition Department specialises in the provision of dietetic services to both adult and paediatric patients. We are looking for Dietitians to join our bank, working as part of the Nutrition Department in the provision of the dietetic service to the Bupa Cromwell Hospital’s patients. You will hold a BSc in Nutrition and Dietetics with HCPC Registration and be able to demonstrate experience in general dietetics with training in Paediatric Dietetics. Our Bank staff provide essential support and cover to our small team of dietitians. You will participate in covering both our Adult and Paediatric Dietetic Service to Bupa Cromwell’s patients on a regular basis, which is clinically evidence based or in line with best-practice. To learn more and apply please contact serina.bunger@cromwellhospital.com

Paediatric Dietitian Band 6/7 Bedford We are looking for a Band 6/7 Dietitian to run paediatric dietetic outpatient clinics at a Bedford Hospital. It’s a 12-minute walk from mainline station to St Pancras. There will not be any obesity or fussy eaters in this clinic, only allergies/intolerances/ failure to thrive. The Dietitian must be confident to diagnose lactose/milk intolerances. Ideally, the role will be for two days per week for 12 weeks. Please call Hayley at Elite for further information on 0800 023 2275 or 01277 849 649. Email: hayley@eliterec. com or visit www.elitedietitians.com

Locum Paediatric Dietitian - SW Birmingham Band 5/6 Paediatric Dietetic Locum required to cover the Midlands (South West Birmingham), from March for at least two months. The position is full time and a combination of Acute and Community. Please call Hayley at Elite for further information 0800 023 2275 or 01277 849 649. Email: hayley@eliterec.com or visit www.elitedietitians.com

Band 6 Dietitian - Kent Band 6 Dietitian required to work in an acute role in Kent, Full time hours for at least 3 months. Position will be covering a renal caseload so candidate would ideally have experience with Renal patients if not the at least 2 years Acute experience. Please call Hayley at Elite for further information 0800 023 2275 or 01277 849649. Email: hayley@eliterec.com or visit www.elitedietitians.com.

Community Dietitian - Adults Peterborough Band 5/6 Adult Community Dietitian to cover a community case load in Peterborough. Applicants must have a car and be able to cover home visits and GP clinics around Peterborough. Start date ASAP for two months, perhaps longer. To be considered for this or other roles with Elite please call 0800 023 2275 or 01277 849 649. Email: hayley@eliterec.com Please follow us on Twitter @elitedietitians our visit our website www. elitedietitians.com for up-to-date jobs.

Diabetes Dietitian wanted Herts A Band 6 Diabetes Dietitian is required for a Hertfordshire trust, covering community clinics, so a car would be ideal. This role starts in March.

Applicants must have DESMOND training and Diabetes background. Please call Hayley at Elite for further information on 0800 023 2275 or 01277 849 649. Email: hayley@eliterec.com or visit www. elitedietitians.com

Band 7 Acute Paediatric Dietitian Essex Band 7 Acute Paediatric Dietitian required for Hospital in Essex. Full time starting from March 21st for at least 5 months as covering a maternity leave.

Must have experience with Neonates. Please call Hayley at Elite for further information 0800 023 2275 or 01277 849649. Email: hayley@eliterec.com or visit www.elitedietitians.com. www.NHDmag.com March 2016 - Issue 112

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Diary dates

events and courses University of Nottingham School of Biosciences

Royal Society of Medicine

Modules for Dietitians and other Healthcare Professionals

• Research methods and critical appraisal course 24th June, 23rd September and 26th November 2016, 10am to 4.30pm

• IBS and Low Fodmaps: 21st April 2016 • Nutrition Support (D24BD2):20th April (International Students only), 21st, 27th & 28th April 2016 • Obesity Management (D24BD3): 6th & 7th October and 8th & 9th December 2016

For further details please contact Lisa Fox via e-mail on lisa.fox@nottingham.ac.uk or check out the University website at www.nottingham.ac.uk/ biosciences www.nottingham.ac.uk/biosciences and click on ‘Study with us’ and then ‘short courses’ which will take you to ‘for practising dietitians’.

1 Wimpole Street, London W1G 0AE

This course will give you five CPD Points.

For more information visit: www.rsm.ac.uk/events/rpg10 or contact Lucy Church, rsmprofessionals@rsm.ac.uk, tel: 0207 290 3928 to book.

To promote your upcoming events or courses here please call 0845 450 2125

University of Nottingham School of Biosciences Modules for Dietitians and other Healthcare Professionals Paediatric Nutrition 10th-11th March www.nottingham.ac.uk/biosciences

University of Nottingham School of Biosciences Modules for Dietitians and other Healthcare Professionals Understanding Behaviour Change 22nd March www.nottingham.ac.uk/biosciences

Adult weight management 11th March – BDA endorsed course HEART Centre, Bennett Rd, Headingley, Leeds LS6 3HN www.bctonline.co.uk

Recipe Analysis: Maximising Accuracy 20th April and 22nd April Kings College London, UK www.susanchurchnutrition.co.uk/recipe-analysistraining/

BDA Live 2016 Incorporating the BDA’s 80th birthday celebrations 16th-17th March QEII Centre, Broad Sanctuary, London SW1P 3EE www.bdalive.co.uk/

Behaviour Change Training Part 1 11th-13th April London Road Community Hospital, Derby www.ncore.org.uk

Nutrition and Hydration Week 14th-20th March info@nutritionandhydrationweek.co.uk www.nutritionandhydrationweek.co.uk

Effective Clinical Supervision Master Class 25th April London Road Community Hospital, Derby www.ncore.org.uk

Advancing Dietetic Practice in Diabetes Training by the British Dietetic Association 21st March 2016 London Road Community Hospital, Derby www.ncore.org.uk

Tackling nutrition in residential care catering and dietetic perspectives 27th April Hospitality House. 11-59 High Road, London N2 8AB www.eventbrite.co.uk

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www.NHDmag.com March 2016 - Issue 112

The final helping 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.

Sports nutrition is our cover story this issue. I have always been interested in sport. My earliest memories are of playing football in our primary school playground at lunch time, taking the bus home at the school gate and immediately going out to play again on a small tarmac rectangle in an adjacent street. The final score of which would usually be something like 26-23!

Back then, in the summer, our thoughts turned to cricket and standing three sticks against the street light with a coat the other side of the road. I can see it now!

Primary education also included organised swimming lesson trips to the open air park baths in ‘spring’. I never did learn to swim until later on in life when my wife taught me the breast stroke . . . honestly.

Grammar school brought with it my introduction to rugby and a tougher challenge. It was rugby for the school in the morning and football for the local team in the afternoon. An injury resulted in me keeping fit by running and soon I had realised the joy of cross country running and a new sport took over. Also at this time, once a week we ran up to the putting green in the adjacent park at lunch times and had a competition amongst ourselves.

Not forgetting the after-school gym club where our basketball nets were upturned chairs fixed on the wall bars at each end of the gym. It was great fun and challenging.

In the summer holidays, I started playing tennis, a short mile walk to the nearest courts. It has been a sport that has kept me enthralled over the years, especially after I finally retired from veterans’ football!

Sport is all about the taking part, but it is also about winning, losing, watching and supporting and the

wonderful life lessons and friendships that you make. It is also, of course, a huge health benefit. In my final year of secondary education, I ran my first and only marathon from Aberdare in South Wales to Brecon, over the Brecon Beacons. I ran with a school friend accompanied by a support team (two other mates in a car) and established a new record for the distance, which had never been run before! It was tough!

Four weeks ago, the Chairman of our local tennis club (180 members) resigned suddenly and a week later at the AGM I was voted into the post. I can say with some confidence that my initial feelings are that the taking part in sport is infinitely more satisfying than having an administrative role, especially if you have one difficult individual who has a different agenda to the rest of the committee and the chairman. But this will improve!

However, Wales are playing France tonight in what promises to be a very exciting rugby match. So, I shall now go and prepare my Welsh Flag, hat, scarf, leek, dragon and replica rugby ball and look forward to a wonderful evening watching and supporting Wales with some very good English friends in our local village pub . . . next to the tennis courts . . . thank you sport.

Oh yes. Childhood Obesity: never heard of it! www.NHDmag.com March 2016 - Issue 112

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