NHD Magazine March 2016 by NH Publishing Ltd

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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

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FROM THE EDITOR

Welcome Emma Coates Editor

Emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the NHS. She has recently moved into industry and currently works as Metabolic Dietitian for Dr Schar UK.

News Flash Changes in medicines legislation for Dietitians. For full details

click here . . .

And so it begins…here comes my first ‘Welcome’ to the latest issue of NHD Magazine as Editor. It only seems like yesterday that I submitted my first article to NHD. But it was over three years ago when I started to contribute as an author and now here I am writing the Welcome page! We work away day-in-day-out at such a fast pace to meet the needs of our patients, keep up with our professional development and fulfil the objectives of our posts, that we can sometimes lose sight of where we have been and where we are heading. So much can be achieved in a short space of time. Only recently have I sat back and taken stock of the last few years. ‘How did I get here?’ is something I’ve asked myself a lot lately! I’ve come to the conclusion that a combination of enthusiasm for dietetics, working hard and making the most of any opportunities to develop my skills and knowledge is what has led me to my current place in the dietetic universe. And now I’m preparing for the next stage in my dietetic adventure as Editor of NHD Magazine. Who knows where it will take me, but I hope you will join me on the journey! Our March issue is jam packed with a diverse range of articles from cystic fibrosis to IBS, to sports nutrition. But to kick off, back once again is Nutrition and Hydration week on 14th-20th March). A week in the calendar where nutrition and hydration is at the top of the agenda for hospitals and care settings around the country. A chance to shout that food really is the best medicine. Andy Jones, Chair of the Hospital Caterer’s Association fills us in on the importance of Nutrition and Hydration week and gives us some suggestions for joining in and making the most of the week wherever you’re working. Caroline Lecko, Patient Safety Lead - NHS England, shares NHS England guidance on commissioning excellent nutrition and hydration and discusses the role of commissioner in making improvements at a local level.

The management of hydration in dysphagia patients is often a challenge, due to the struggles that patients experience with finding a suitable and palatable thickener. Speech and Language Therapist, Sheri Taylor, gives us an overview of thickeners and their application, with some excellent advice for choosing thickeners for patients. We have included two fantastic sports nutrition articles this month: a case study from Claire Chaudhry, Freelance Dietitian, which focuses on the effects of poor nutritional intake and its impact on a male runner’s training and competing performance. Gemma Sampson RD explores the role of gluten-free diets for athletes, investigating the evidence and whether they have an impact on performance. IBS treatment options, guidance and pathways are discussed by Ali Hutton RD in her informative article, which looks also at the important role of the dietitian in the management of IBS. Another condition where dietetic input is absolutely vital is cystic fibrosis (CF). Jacqui Lowden RD leads us through the nutritional requirements and recommendations for CF patients along with factors which impact on these requirements. Ehlers-Danlos syndrome and dietary interventions are discussed by Janet Dennis RD in an article which highlights a condition where the management of various symptoms benefits from a multi systemic approach. And finally, Ursula Arens explains why she’s changed her mind about Gwyneth Paltrow and her dietary advice. Trust me, it’s worth a read! www.NHDmag.com March 2016 - Issue 112

Contents

14 COVER STORY

Sports nutrition and the gluten-free diet 6

News

Nutrition and hydration week

Latest industry and product updates

14th-20th March 2016

10 Nutrition and hydration NHS England guidance for commissioners 17 Sports nutrition Case study: performance running

43 Cystic Fibrosis Nutritional requirements 47 Ehlers-Danlos syndrome Can diet help with symptoms? 50 I have changed my mind . . . Dietetic considerations from Ursula Arens 53 Web watch Online resources and updates

25 Infant weaning Getting the best start

55 A day in the life of . . . Navigating the world of charity

31 Dysphagia All you need to know about thickeners

57 dieteticJOBS Latest career opportunities

38 IBS

58 Events and courses Upcoming dates for your diary

Dietetic management

59 The final helping The last word from Neil Donnelly

All rights reserved. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dawson Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst

Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk

@NHDmagazine

Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

www.NHDmag.com March 2016 - Issue 112

ISSN 1756-9567 (Print)

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 . . .

www.NHDmag.com March 2016 - Issue 112

Folic acid fortification There has been much in the news about pushing forward with folic acid flour fortification in Scotland and possibly the rest of the UK. This largely seems to stem from one new metaanalysis paper. The article published in The American Journal of Public Health reviewed evidence from 123 papers looking at folic acid fortification and prevalence of spina bifida. It was found that the prevalence of spina bifida was lower with 33.9 per 100,000 live births in areas with mandatory fortification compared with 48.3 per 100,000 live births in areas with voluntary fortification. Overall, authors concluded that spina bifida was significantly more common in world regions without mandatory folic acid fortifications, indicating that Asian and European countries, including the UK should perhaps look into revisiting policies. That said, Europe has held back from folic acid flour fortification for good reason. One was due to links with certain cancers in adult populations exposed to folic acid fortification and supplementation. Now, a new study carried out in Ireland has looked at how voluntary folic acid fortification altered levels of unmetabolised folic acid (UFA; metabolic overspill) in children. Fasting samples of 68 children attending the Children’s Hospital in Crumlin were analysed and plasma folate, red blood cell folate and UFA levels measured and grouped according to age. UFA was found in 10% of the samples. Mean plasma folate and red blood cell folate concentrations were 35.1nmol/L and 956nmol/L respectively and mean daily folic acid intake (from foods and supplements) was 109μg. Overall, UFA was found in the plasma of around 10% of children after an overnight fast. Subsequently, authors recommended that this should be considered by policy makers in control of folic acid fortification. So, while women of childbearing age would clearly benefit from mandatory folic acid fortification, it is less clear how this could impact on the health of other population groups that are less in need of folic acid.

Latest on protein

Health Vol 106, no 1, pg 159 and Vaish S et al (2016). Am J Clin

Benefits of protein for sport and exercise Vol 15, no 5, pg.50-52.

For more information, see: Atta, CA et al (2016). Am J Public

Nutr [Epub ahead of print].

Sarcopenia (low muscle mass) is a hidden and potentially harmful condition where we lose muscle as we age. Typically, from the age of around 30, those who are not physically active can lose up to 5% of their lean muscle every decade. In turn, this can drive up the risk of falls, injury and arthritis. A new article published in the Proceedings of the Nutrition Society explains that this is even more of a problem when coupled with obesity; a condition known as ‘sarcopenic obesity’. Together, the combined effects of obesity and sarcopenia have been associated with greater physical impairment, poorer surgery outcomes, shorter time to tumour progression and shorter survival. Now, more work is needed to decipher why this seems to be the case. Another review in Complete Nutrition authored by Dr Ruxton from the Meat Advisory Panel, explains that even sporting enthusiasts may be at risk of protein catabolism (muscle breakdown) which in the long-term can also contribute to sarcopenia. This tends to be the result of intense training or physical exertion combined with insufficient protein intakes, such as lack of lean red meat. Over time, catabolism can also reduce immunity and the digestive function. Taken together, obtaining a healthy body weight and optimal level of lean muscle mass is central to healthy ageing. For active individuals, increased exertions should be matched with suitable intakes of protein from protein sources such as lean red meat, alongside resistance training, which has been found to be particularly beneficial in improving lean body mass.

For more information, see: Prado CM et al. (2016). Proc

Nutr Soc [Epub ahead of print] and Ruxton C & Cobb R (2015). www.meatandhealth.com. For recipes please visit www.meatmatters.com. www.NHDmag.com March 2016 - Issue 112

Product / Industry News

NEWS Potatoes for potassium? Dietary Guidelines In 2020, new American Dietary Guidelines will include recommendations for children from birth to 24 months of age. Considering this, scientists analysed how fruit and vegetable intakes in early life could contribute to nutrient intakes using data from the National Health and Nutrition Examination Survey. Amongst children aged one to three years, average intakes of potassium, dietary fibre and vitamin D were 67%, 55% and 49% of Dietary Reference Intake, respectively. Mean total vegetable intakes were also less than advice of one cup per day. Authors concluded that the consumption of all vegetables, but especially those rich in potassium and dietary fibre, such as potatoes, should be encouraged to help narrow these gaps. In another study, the effects of replacing a cup of vegetables with a cup of white potatoes was examined. It was found that the percentage contribution of the potato composite to daily nutrient intakes was 6% for total energy, 8% for total fat, 5% for saturated fatty acids, 13% for dietary fibre, 4% for sodium and 11% for potassium. In summary, while both composites provided an array of nutrients, the consumption of white potatoes may be particularly important in helping to meet potassium recommendations.

For more information, see: Storey

ML and Anderson PA (2016). Adv

Nutr Vol 7, no 1, pg 241S-6S

and Nicklas TA et al (2016). Adv Nutr Vol 7, no 1, pg 247S-53S.

www.NHDmag.com March 2016 - Issue 112

Important News for VitasavouryTM 200

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Fruit and veg for diabetes prevention There has been mixed evidence about whether fruit and vegetables, eaten separately or combined, reduced Type 2 diabetes risk. Now, a new meta-analysis has collated evidence from available research. The analysis included data from 23 articles, taking place over 10 years or more. Scientists found that higher intakes of fruit, especially berries, green leafy or yellow vegetables, cruciferous vegetables and fibre content were associated with reduced Type 2 diabetes risk. These are important findings given rising rates of Type 2 diabetes. Aiming to achieve the five-a-day fruit and vegetable benchmark may go some way to helping offset Type 2 diabetes risk.

For more information, see: Wang PY et al (2016). J Diabetes

Investig. Vol 7, no 1, pg 56-69.

PUBLIC HEALTH

Nutrition and Hydration Week 14th to 20th March 2016 Andy Jones Chair of the Hospital Caterer’s Association (HCA)

There needs to be far greater recognition of the importance of nutrition and hydration, says Andy Jones. Getting involved in Nutrition and Hydration Week (NHW) is a great way to heighten awareness…there’s still time to join in!

We all know the importance of good nutrition and hydration don’t we? To me, the importance of food and drink in healthcare and social care has never had such importance as it does now. We often hear the words ‘obesity’ and rightly so, as we can see the issues all around us, but when malnutrition or undernutrition is mentioned, then that’s a different matter and to the public, this is something that is not an issue in the modern world. There needs to be far greater Monday - Big Breakfast - the most recognition of important meal of the day Tuesday - Bedtime Snack - without this the importance there are over 12 hours without planned of nutrition food intake and hydration, Wednesday - Global Tea Party - due to the massive success of our World Tea Party, after all, when we are looking to achieve an official World we are ill, food Record attempt in 2016 and we would is the best form encourage you to consider whether your organisation could become a record breaker. of medicine. In Thursday - Thirsty Thursday social care, the Friday - Fruity Friday and or Fishy Friday importance of good nutrition and hydration is so important to protect the NHS from the burden that malnutrition of the elderly patients undoubtedly places on the budget. Once again, NHW is supported this year by Patient Safety First (PSF), Hospital Caterer’s Association (HCA) and National Association of Care Catering (NACC). Our aim remains unchanged: To create a global movement to reinforce and focus energy, activity and engagement on nutrition and hydration as an important part of quality care, experience and safety improvement in health and social care settings. We have updated our resources so that you can start planning if you have not already done so. 2016 planner, posters

Andy has been a stalwart of patient catering for over 30 years, with the key influence being the delivery of a nutritious and wholesome food and hydration service to all patients at ward level.

and logos are all in the resources section at www.nutritionandhydrationweek.co.uk This year we have also identified different daily themes for you to get engaged with (see box). What can you do around the week?

One area that we want to see developing is the Junior NHW Ambassadors, which started in 2015 with great success and we have plans to develop this further for 2016 and beyond the week. Educating the young is fun and is great way of embedding the ethos of good nutrition and hydration. Find out more at www. nutritionandhydrationweek.co.uk/ campaign-resources/case-studies/ There’s still time to join in

As a team, we have signed up to the Nutrition and Hydration Week Charter, with one of our commitments being to support education and training. In order to fulfil this commitment, we have developed a Continual Professional Development framework to support you in demonstrating professional development through the activities you support as part of Nutrition and Hydration Week. You will find the framework at: www.bit.ly/1guvDh4 We really hope that you find all of these resources helpful and we look forward to hearing about your Nutrition and Hydration Week in 2016. We continue to be amazed by your endeavours in promoting good nutritional care wherever you are. Thank you. The Nutrition and Hydration Week Team: Andy Jones, Caroline Lecko and Derek Johnson Keep up to date with the team and the events etc, on Twitter @NHWeek www.NHDmag.com March 2016 - Issue 112

nutrition and Hydration

Commissioning Excellent Nutrition and Hydration: NHS England guidance Caroline Lecko Patient Safety Lead - NHS England Caroline has led on nutrition and patient safety since joining the National Patient Safety Agency (NPSA) in 2006 and has subsequently transferred to the patient safety domain team within the NHS England. She has worked on a range of national and international projects to raise awareness of the importance of good nutritional care.

In October 2015, NHS England published guidance to support commissioners in the commissioning of nutrition and hydration services. This article discusses the background to the development of the guidance and the role of commissioners in improving nutrition and hydration locally. In October 2015, NHS England published guidance to support commissioners in the commissioning of nutrition and hydration services. This article discusses the background to the development of the guidance and the role of commissioners in improving nutrition and hydration locally. NHS England’s guidance, Commissioning Excellent Nutrition and Hydration2, published in October, was timely given the recent figures release by the British Association of Parenteral and Enteral Nutrition (BAPEN),1 which estimates the cost of disease-related malnutrition in England to be a staggering £19.6 billion annually - more than 15% of the total public expenditure on health and social care.

‘All people will receive safe and high quality nutrition and hydration support when required, through the commissioning of person-centred and clinically effective integrated services in the community and in healthcare commissioned settings.’ Published as part of NHS England ‘Hard Truths’ programme in response to the Francis report (Francis 2013)3, the guidance also supports the Department of Health’s request to develop strategies to improve the provision of nutrition and hydration services in hospitals. The guidance has been developed to support commissioners of services, by providing examples of different approaches that could be adapted locally to drive improvements within a local population. In 10

www.NHDmag.com March 2016 - Issue 112

order to achieve this, NHS England worked with a wide range of stakeholders including clinical commissioning groups, the voluntary sector, professional associations, regulators, the Department of Health, carers and users of services. Within the guidance, the scale and impact of both malnutrition and dehydration are outlined to provide context and the responsibilities of commissioners in relation to the services they commission are highlighted. Whilst the guidance is not mandatory, it does set out key outcomes for commissioners to achieve by 2018. The responsibilities of commissioners

The guidance identifies the key responsibilities of commissioners in relation to nutrition and hydration, with the ambition of preventing malnutrition and dehydration from occurring by: • identifying when malnutrition has occurred through the use of active nutritional screening, e.g. using the Malnutrition Universal Screening Tool (‘MUST’) tool for adults and an appropriate paediatric screening tool; • specifically treating those at risk from malnutrition or dehydration using documented appropriate NICE compliant care pathways (utilising food, drinks, oral nutritional supplements and safely administered tube or intravenous feeds/fluids as necessary), with ongoing specific care spanning organisational boundaries where needed www. malnutritionpathway.co.uk • educating all staff, voluntary workers, patients and carers on the importance

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;

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

nutrition and Hydration 10. Ensure patient/service user involvement in service development and quality assurance of commissioned services taking into account the needs of diverse communities. 11. To ensure that paediatric services are delivering high quality and safe services for child and young people in a child-friendly setting with appropriately trained staff. 12. To ensure that children and young people grow and develop normally and monitored according to growth centiles.

Whilst the key outcomes previously identified may appear ambitious, there is an abundance of guidance and resources already available to support commissioners. How can commissioners achieve these outcomes?

Whilst the key outcomes previously identified may appear ambitious, there is an abundance of guidance and resources already available to support commissioners. Throughout the guidance examples of a range of different approaches currently used are shared, along with signposting to specific key documents from national and professional organisations. In addition to this, four areas of activity are highlighted as they are seen as fundamental to ensuring that the outcomes are achieved: • Understand your current position • Develop commissioning improvement plans • Provide education and training • Develop quality indicators to support monitor and review The guidance also demonstrates that there are existing tools available to assist with the monitoring and evaluation required to achieve the objectives and outcomes, but does acknowledge that commissioners may wish to develop to their own local indicators.

Taking forward implementation

Implementation is always a challenge, so a range of different approaches are being taken to leverage adoption of the guidance. Key to this is the engagement with the Malnutrition Task Force, other NHS organisations, professional groups, charities and industry to support implementation. In addition to this, early discussions have taken place with the Care Quality Commission (CQC) to discuss how the guidance could be used to improve nutrition and hydration through the inspection process. There are early plans underway to engage with some Clinical Commissioning Groups (CCG), including an evaluation by Kings College London with three Clinical Commissioning Groups to gain a baseline of current activity and how the guidance has been implemented. Discussions have also taken place with one of the Care Home Vanguard sites to consider implementing the guidance as part of their programme and a further five CCGs, which form a strategic collaborative commissioning group, are proposing to have one CQUIN to ensure that they are ‘commissioning excellent nutrition and hydration’ services for all nine acute providers. It is also hoped that the CCGs that were involved in the development of guidance will now take forward implementation. Conclusion

Commissioning Excellent Nutrition and Hydration provides a framework for commissioners to drive forward improvement in the nutrition and hydration across their local population. The guidance outlines the key responsibilities and outcomes for commissioners to fulfil a vision providing safe, high quality care in order to prevent malnutrition and dehydration. The challenge now is to drive forward adoption and implementation - a responsibility that sits with us all.

References 1 British Association of Parenteral and Enteral Nutrition (2015). The cost of malnutrition in England and potential cost savings from nutritional interventions www.bapen.org.uk/professionals/publications-and-resources/bapen-reports (accessed 18 Dec 2015) 2 NHS England (2015). Commissioning Excellent Nutrition and Hydration www.england.nhs.uk/commissioning/nut-hyd/ (accessed 18 Dec 2015) 3 Francis R (2013). Report of the Mid-Staffordshire NHS Foundation Trust Public HMSO Inquiry Crown Copyright

www.NHDmag.com March 2016 - Issue 112

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cover story

Gluten-free diets for athletic performance Gemma Sampson Registered Dietitian, Senior R&D Dietitian, Vitaflo International Gemma has experience as a registered dietitian in a variety of clinical and industry settings, with personal interests in sports nutrition, gluten-related disorders and plant-based lifestyles. She runs the nutrition blog Dietitian without Borders (www.dietitian withoutborders. com/)

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

Elite and amateur athletes have long been manipulating their diets in an attempt to gain a competitive edge over their opponents. The trend to adopt a glutenfree diet in the absence of coeliac disease, or non-coeliac gluten sensitivity, has rapidly increased amongst the general population, with claims of improved health benefits and weight loss potential.1 In this article, Gemma Sampson examines perceived performance enhancement of the gluten-free diet. The increasing popularity of a glutenfree diet extends to athletes, with many high profile athletes promoting its perceived performance enhancing effects. With 11-41% of athletes reporting to currently follow a gluten-free diet 50100% of the time, the trend for athletes following a gluten-free lifestyle is likely to only increase.2-4 A large survey exploring the popularity, experiences and beliefs surrounding gluten-free diets captured athletes from a broad range of sports and competitive levels, including 18 World and Olympic medalists.3 While gluten-free diets are followed by athletes competing in a variety of sports, including tennis, running, cycling and endurance events, endurance athletes in particular appear more likely to adopt a gluten-free diet for performance enhancement.2-5 gluten-free diet: Perceived performance enhancement

Despite a lack of clinical evidence supporting the use of a gluten-free diet to enhance performance in sport, many athletes anecdotally report that it enhances their training, recovery and gives them a competitive edge.2,3,5 Considering the popularity of gluten-free diets amongst athletes, little published research has thoroughly evaluated outcome measures of performance to justify these claims. Dietary changes amongst elite athletes appear to be primarily performance driven; however, a gluten-free diet may 14

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also be adopted by athletes to reduce gastrointestinal distress.2-5 Forty-one percent of the 910 athletes surveyed by Lis et al (2015) reported following a gluten-free diet as it provided a performance advantage.3 Of seven elite female runners, five (71%) reported either avoiding gluten exclusively or limiting their gluten intake.5 Three reported perceived improvements in their performance and training, while the other two stated reduced digestive distress as a result of going gluten free.5 To date, only one study has evaluated the short-term impact of gluten intake upon performance outcomes as part of a controlled, randomised, doubleblind crossover study in endurance cyclists.2 No overall effects were found on performance, gastrointestinal (GI) symptoms or wellbeing as a result of consuming 16g of wheat gluten per day. Within the study, cyclists excluded from coeliac disease with no history of irritable bowel syndrome were randomly allocated to follow a glutencontaining diet or gluten-free diet for seven days, with each intervention separated by a 10-day wash-out period. All participants were educated by a dietitian and provided with a glutenfree diet during both interventions, consuming two quinoa-based food bars that were either gluten-free made with whey protein or contained a total 16g of vital wheat gluten. These were spread across the day to represent typical gluten intake patterns.

PUBLIC HEALTH

In this study, to avoid false improvements in performance, athletes undertook a familiarisation session of the performance test before commencing the first dietary intervention. VO2 Max was established for each participant 10 days prior to commencing the trial and results from an incremental exercise test used to prescribe the intensity of the steady-state exercise ride: 70% Wmax for 45 minutes, followed by a 15minute Time Trial (TT) - both well measured and validated performance measures. On day seven there was no significant difference between performance measures of power, heart rate, cadence or total work competed over the 15minute TT. Neither was any difference detected between gastrointestinal wellbeing, overall wellbeing, or inflammatory measures.2 Self-diagnosis and dietary exclusion, without support or diagnosis from a dietitian or suitable healthcare professional, is common.2 Athletes experimenting with their diet perceived that a gluten-free diet increased their performance and reduced GI distress.2 Athletes who avoided gluten felt that their performance was impaired whilst consuming gluten and that their improved performance after excluding gluten was possibly related to low-level inflammation.5 These athletes were unlikely to have been tested for coeliac disease or non-coeliac gluten sensitivity prior to making dietary changes. As reduced GI distress as a result of excluding gluten may be a valid factor resulting in improved performance, it is important to appropriately screen for and exclude any of these underlying conditions.

The belief concept

Despite the limited evidence supporting the use of a gluten-free diet to enhance performance, its popularity continues to increase. Athletes may perceive improvements in their energy, pace and other aspects of performance, even if this is not observed with test results.6 After excluding dietary gluten for four weeks, one athlete reported feeling an increase in energy and pace despite a lack of actual increase in pace.6 Three female athletes reported improvements in running times and training quality after following a gluten-free diet; however, this was not tested or confirmed.5 Over 56% of athletes surveyed believed that a glutenfree diet improved their performance, with 74.4% believing it improved body composition for improved sport performance.3 Belief in a novel and exciting performanceenhancing treatment can produce improvements in performance, regardless of whether a real treatment effect exists.7 Belief in an intervention can contribute 1-3% improvements in performance, regardless of whether there are any ergogenic mechanisms to support this.7 Also known as a placebo effect, the belief concept plays a complicated role in influencing outcomes, with evidence supporting that enhanced performance in athletes has a neurobiological basis which can involve psychological, social and neurological changes associated with expectation, reward, hope and reduced anxiety or stress.7 Athletes may follow a gluten-free diet due to perceived physiological improvements that coincide simultaneously with other positive dietary changes influencing health.3 www.NHDmag.com March 2016 - Issue 112

SPORTS NUTRITION Nutritional adequacy of the gluten-free diet

Eliminating gluten from the diet may either improve or compromise an athleteâ&#x20AC;&#x2122;s diet, depending upon baseline nutritional quality. Interestingly, 77.9% of athletes surveyed believed that following a gluten-free diet increased their conscientiousness of eating a healthy and balanced diet, prompting them to eat less processed food and eat more fruits, vegetables and gluten-free wholegrains.3 Most athletes obtain dietary information about gluten-free diets from online sources, trainers, coaches or other athletes.3 Only 14% of athletes surveyed obtained their information on the gluten-free diet from a registered dietitian/ nutritionist.3 As dietary changes are often made experimentally by the athlete without the support of a dietitian or suitable health professional, this could result in nutritional inadequacies.2,3,5 Prior to excluding gluten, athletes should be encouraged to test for coeliac disease, irritable bowel syndrome or non-coeliac gluten sensitivity to exclude any underlying medical conditions which may impact their performance or GI distress. Perceived performance enhancement of the gluten-free diet may result from underlying conditions, belief in the diet, or through improved dietary quality as a result of increased fruit and vegetable intake, together with lower consumption of refined carbohydrates.3,8 Comparison of dietary practices between those medically diagnosed or self-diagnosed with gluten sensitivity indicates that 77% of individuals reported reduced carbohydrate and sweet intake after starting a gluten-free diet and 63% increased their consumption of fruits and vegetables.8 A gluten-free diet has been associated with inadequate intakes of B-vitamins, thiamin, riboflavin, niacin, folate, iron and fibre.9 International assessment on the nutritional quality of commercially available gluten-free foods shows that, contrary to popular opinion of being healthier alternatives, gluten-free foods are frequently lower in protein, higher in carbohydrate, lower in fibre and lower in micronutrients iron, zinc and magnesium, at an increased cost.9-11 Inadequate intake of any of 16

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these nutrients could severely impact athletic performance if not adequately addressed. While athletes may take supplements to avoid micronutrient deficiency,5 it is important to evaluate the overall nutritional quality of the diet to ensure it is adequate in both macronutrients and micronutrient intake. Ensuring a diverse range of gluten-free grains are consumed is important to help athletes obtain the benefits of wholegrains and avoid nutritional deficiencies.1 A gluten-free diet can be well balanced by including adequate fruit and vegetables, legumes, suitable wholegrains and by selecting gluten-free foods with a lower energy density. Research is emerging on the influence that dietary change and dietary restrictions have on gut bacteria populations and gut health.1,12 A gluten-free diet has been associated with potentially adverse changes in gut health, while a diet containing wheat has been found to improve beneficial gut bacteria populations.1 A low-FODMAP diet used to manage irritable bowel syndrome typically excludes gluten and demonstrates negative gut bacteria changes in as little as four weeks.12 Further research is required to determine the effects of long-term adherence to a gluten-free diet on parameters of exercise performance and gut health.2,3,12 Conclusion

An athleteâ&#x20AC;&#x2122;s diet plays a critical role in training adaptations and athletic performance. While there is no published evidence supporting the notion that a gluten-free diet enhances performance, many athletes perceive a beneficial effect and may wish to remove gluten to gain a competitive edge. Belief in the gluten-free diet may improve perceived performance, despite any detectable treatment effect. Nutritional considerations for athletes following glutenfree diets should focus on including a variety of gluten-free wholegrains to limit potential micronutrient deficiencies, ensure adequate fibre intake and lower glycaemic index. As many sports supplements, foods and drinks designed for athletes competing in ultra-endurance events contain gluten and are unsuitable for someone following a gluten-free diet, advice on suitable alternatives is required.

public health

sports nutrition: CASE STUDY Claire Chaudhry Community NHS Dietitian/ Private Sports Dietitian, Claire Sports Nutrition Consultancy In Claire’s 13 years’ experience, she has worked in acute and community NHS settings. She has taught nutrition topics at universities and colleges and regularly provides talks to groups, in the NHS and in private practice (www.dietitian claire.com).

In this case study, Claire Chaudhry examines how poor nutritional intake affects an athlete’s ability to train, recover from training, compete and continue to compete.1 Coaches and athletes are more aware than ever that in sport, diet is essential to improving health and sports performance. Good nutrition enables athletes to build and repair

body tissue, regulate metabolism, obtain energy and nutrients, maintain immune function and effectively utilise glycogen stores when required for sports performance.

Client A, Adult, Male, Runner Identification of nutritional need: dietetic aims of sports nutrition Aid performance pre-, during and post-exercise; reduce fatigue, increase endurance and aid recovery of the body. • Maintain sufficient dietary carbohydrate intake during training and competition. • Maintain energy balance. • Maintain muscle glycogen levels. • Maintain weight. • Maintain sufficient fluid intake, to maintain normal thermoregulatory function during exercise. Preventing dehydration which can reduce physical ability and increase fatigue. • Maintain adequate dietary micronutrients, i.e. calcium and iron.

Pie Chart 1: Recommendations of percentage of daily kcal requirements from 3 macronutrients in sports nutrition 1. Assessment Client A is a male, age 36 ,weight 78kg, height 6 foot 1 inch BMI = 22.6. BMIs in athletes provide limited information on body composition due to increased muscle mass in the athlete. Client A completed a food diary and consecutive physical activity level (PAL) diary for seven days in October 2015. PAL diary reveals that client A is a regular outdoor runner with combined strength training. Client A averages >2 hours intensive running weekly, divided into two by one-hour + running sessions across a mixture of forest and road terrain. He adds in 10 minutes of strength training half way through his runs with press ups, sit ups and pull ups at his local outdoor gym. In the past he has trained and completed many competitive runs: The Great North Run www.greatrun.org/great-north-run and The Mighty Deerstalker www.ratrace.com/mightydeerstalker. He is currently training to compete in the Wales trail marathon www.trailmarathonwales.com in June 2016 and a Tough Mudder www.toughmudder.co.uk in September 2016. Client A wanted to assess his macro and micro nutrients to ensure he is obtaining good nutrition in order to train, compete and recover. www.NHDmag.com March 2016 - Issue 112

PUBLIC HEALTH Table 1: Client A’s calculated requirements Nutrients and fluid

Client A’s calculated requirements2,3,4,5,6,7

Kcal (calories)

3060-3363kcals

Carbohydrate

390gm-780gm (higher range race day) (or providing 55-70% (higher range race day) of total kcal

Protein

93gm-132gm (providing 15% of total kcal)

Fat

Lower weight <20% of total kcal intake Higher weight <35% of total kcal intake Of total fat: Saturated fat <11% and Trans fats <2%

Vitamin and minerals

Diet to meet DRVs EAR/RNI. Supplements not required unless low intake in diet and or deficiency has been recognised

Fluid

1950-2730mls or 2.5litres per day as a male

2. Identification of nutrition and dietetic diagnosis Client A’s diet is very varied; he eats regularly and understands the importance of glycogen storage in muscles and liver and the need for carbohydrates. Using a nutritional analysis programme, web based and based on McCance and Widdowson,8 Client A’s average mean daily intake over the seven days was calculated and compared with the recommendations:

Pie Chart 2: Percentage of daily mean kcal provided by 3 macronutrients (+alcohol for client A over 7 days Calories 2798kcals which are slightly under his recommendations calculated (3060-3363kcals daily). However, his daily kcal range varied from 1958kcals to 5088kcals daily. Over a seven-day period his dietary intake met his kcal requirements. Protein 86.5gm of protein which is slightly under his calculated requirements (93gm-132gm). His mean intake provided 12% of his total kcal from protein, Client A’s target is aiming for 15%. His protein daily intake ranged from 48gm to 135gm. There was only one day when he didn’t meet the protein requirements for the general population (55gm of protein). Carbohydrate 373gm of Carbohydrate which is slightly under his recommendations over seven days (390gm-780gm) providing 50% of his total kcal intake from carbohydrate. Client A’s target is between 55-70%. His intake ranged from 281gm to 541gm. The ratio of simple sugars (glucose to fructose) can be an important factor in running. A runner may benefit with more glucose to fructose ratio during training to help with greater absorption and less gastrointestinal (GIT) disturbances.9 Client A’s diary showed the mean intake of his glucose was higher than the fructose. Client A only suffers from GIT disturbances after competitive races. Fibre 22gm of NSP and 22.6gm of AOAC daily fibre from Client A, therefore meeting the daily recommendation from SACN report, 2015, adults 18gm-30gm daily.10

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Fat Bar Chart 1: Macro and micronutrients percentage obtained of Total fat provides 107gm (963kcals daily) DRVs for Client A which is nearly 35% of his total kcal intake. Out of the total fat, mean saturated fat intake is 35gm (providing 11% of total kcals) and trans fat 1.3gm (providing 0.4% of total kcals). The population of the UK on average gets 12.6% of their energy (kcal) from saturated fats. The average male should aim to have no more than 30g of saturated fat a day (<11% from total kcals). Trans fats aiming for <2%, for adults this is no more than about 5.0g a day. Client A’s diet shows that his saturated fat consumption was higher than it should be, but lower than the general population. His trans fats consumption was low. Fluid Client A’s mean intake over seven days is 1383mls from dietary intake, i.e. fruit, coffee, wine, beer and milk. He also drinks at least two litres of water daily averaging 3383mls daily. Client A monitors his urine output and increases his fluid intake after exercise. Vitamins and minerals The average mean intake of his vitamins and minerals met his required DRVs - RNI for Client A, apart from selenium, zinc and potassium. (See Bar Chart 1.) Sodium Mean sodium levels were high; although you would expect to see that in the general population. Vitamin D Vitamin D is essential in the adult body for bone health and in some studies on adult males, there is a link with muscle strength.11 In the UK, an RNI has not been set for groups in the population, considered to receive adequate sunlight exposure. There is an assumption that the amount of vitamin D produced by exposure to summer sunlight, would produce enough vitamin D for their needs during winter. Client A does not fall into any of the categories that require a vitamin D supplement, i.e. pregnancy, lactation or a male over 50 years old which is10mcg daily. Client A’s mean vitamin D intake over seven days was 1.5 micrograms, this ranged from 0.1-3.1 micrograms daily. The sun provides 80-90% of Vitamin D requirements absorbed through the skin. Food sources, i.e. salmon, tuna, pilchards, mackerel, eggs and dairy, provide between 10-20%. SACN reported that, ‘Adults with 35% skin area exposed (equivalent to wearing modest shorts/skirt and T-shirt) at around noon (12:00-13:00) from March to September, the daily exposure time to reach the end of summer (September) to obtain target serum 25(OH)D concentration would be nine minutes for skin types I-IV (white) and 25 minutes for skin type V (south Asian ethnicity)’.12 Deficiency of a nutrient cannot be diagnosed on the basis of dietary assessment alone.13 However, there are a number of factors that are putting Client A at risk of being vitamin D deficient: • Client A is outside in the midday sun in summer at weekends only, therefore reducing his sun exposure. 2015 summer in Wales had an increase rainfall than normal.14 • Client A wears factor 30 sunscreen for the majority of the time, which reduces cutaneous vitamin D production in the body. • Client A is also not that keen on fish and doesn’t have fish regularly in his diet. • Client A is of Asian background, therefore his skin requires more time in the sun compared to skin type I-IV. • Studies on intakes suggest an increased risk of vitamin D deficiency in all ages and sex groups15 and there was a prevalence of vitamin D deficiency amongst adults in Europe ranging between 2-30% of the adult population.16

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PUBLIC HEALTH 3.Plan nutrition and dietetic intervention Once analysed, I met with client A for an hour-long consultation. Based on the findings of the dietary analysis, the following was discussed: • Increase CHO as the % of kcals coming from carbohydrate was below the recommended 55-70%. Extra portions of porridge at breakfast, increase portions of pasta and rice with his meals. Encouraged to monitor weight weekly to ensure weight remains stable. • Reduce fat intake to reduce to <35% of his total kcals. Client A’s intake of natural yoghurt was not low fat and a large proportion of his saturated fat came from this and hard cheese. Advised to change to low fat yoghurt and taught how to look at labels more clearly, looking at fats in relation to heart health. • Protein intake to increase from providing 12% of total kcals to 15%. Portions of protein rich foods recommended increasing at meal times. DOMS (delayed onset muscle soreness) discussed, as around 15-25gm of protein within an hour after exercise can help with muscle recovery.17 • Abstain from alcohol during intensive training Alcohol mean intake over the week provided 3% of his total kcals; this was in fact over two days consumed. Alcohol reduces glycogenolysis (glycogen breakdown) in the liver and thus may hamper performance during training and competing.18 • Vitamin D increase with fish or take a supplement. Advised to get a blood test Increasing fish consumption in Client A’s diet will also increase his protein intake, and provide a low fat protein source rather than hard cheese. Encouraged to have salmon or tuna on a sandwich two to three times a week (100gm of tinned salmon can provide nearly 14 micrograms of vitamin D). Client A is not that keen on fish, therefore there was a rationale to recommend a vitamin D tablet daily with a low dose of 5 micrograms (200IU) in the winter months. According to the FSA, this dose is unlikely to cause him any harm.19 I recommended that he obtain a serum blood test from his GP (25-hydroxy vitamin D) to check his vitamin D status. Note -OTC (over the counter) vitamin D supplements without calcium tend to come in doses of (vitamin D3) 1000iu 25 micrograms. Advised Client A to have a quarter tablet daily from December to March. • Zinc Zinc is essential for metabolism of proteins, carbohydrates and lipids. Zinc is found in meat and shellfish; intake can be increased with increasing fish consumption as above and eating red meat once a week. • Selenium Selenium acts as an antioxidant, protecting the body against oxidative damage. Selenium rich sources include nuts, meat, shellfish, dairy and cereal. I suggested nuts as a snack which will increase this mineral, as well as provide protein and monounsaturated fats. Nine whole brazil nuts will provide his daily RNI of selenium. • Potassium Potassium in the body is essential for physiology of nerves and muscles and acid base regulation of cells. Potassium deficiency arising from inadequate dietary intake is extremely unlikely. Small amounts of potassium are lost from sweating during exercise, but not enough to have an impact on a well-nourished and healthy adult. Explained to Client A that not obtaining the RNI was not a cause for concern. • Sarcopenia Some loss of muscle mass is inevitable and is a consequence of aging, skeletal muscle mass declines by 0.5-1% per year once past 40 years of age. The importance of strength training and protein intake was emphasised given Client A’s age.20 • Caffeine as an ergogenic aid Client A regularly has a mug of coffee every morning, two mugs at the weekend. Studies have shown that caffeine can have an ergogenic effect on endurance performance, only in people who are not accustomed to caffeine. The athlete must abstain from caffeine for a minimum of seven days before a race, then consume around 3mg per kg (234mg) or a dose of 250mg, taken pre-race or at the end of the race which can improve endurance and performance.21 Client A informed me that he is very sensitive to the effects of caffeine, therefore encouraged to trial the above in training first and not during a competitive run. Suggested to abstain as above and then have a coffee before the run (40-163mg), or trial caffeine in gel form towards the end of his run (<100mg). • Pre race and race day nutrition discussed briefly Reduction of fibre one to two days before run to help with reducing GIT disturbances. Timings were revisited according to the ISSN recommendations22 and practical recommendations.23

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PUBLIC HEALTH 4. Implement nutrition and dietetic intervention As discussed in the consultation, using Client A’s current weekly dietary intake, examples of his new daily meal plans were provided, which met the recommendations. Extra literature was supplied, i.e. portion sizes, protein containing foods, labelling information. 5. Monitor and review As discussed in the consultation, using Client A’s current weekly dietary intake, examples of his new daily meal plans were provided, which met the recommendations. Extra literature was supplied, i.e. portion sizes, protein containing foods, labelling information. 6. Evaluation “Claire has provided me with nutrition advice in the past, particularly regarding carbohydrate snacks and timings with my running. This advice actually helped in races and I felt that I ran better than before and recovered better with my energy levels, so I trust her advice as it has proved useful in competition. “I wanted to have a full dietary analysis to see how my general diet was and I am glad I did. I hadn’t realised I needed more carbohydrate and less fat and I wasn’t having the proportion of fats correctly to help prevent heart problems later on in life. My vitamin and mineral results are mostly meeting the required levels, apart from vitamin D, as I have never really taken to eating fish! Claire sold it to me well and I am going to try with having salmon or tuna weekly and, if not, then the vitamin D supplements are there for me to have over the winter months. I am pleased Claire mentioned the protein timings as, again, this will help me with recovery and I was surprised at the muscle mass loss, so I will certainly be keeping up my strength training. I usually do stop my alcohol a month before the race, as I personally can feel a negative effect the next day after having one or two drinks. Before my next race in June I will ask Claire to analyse my weekly diet again just to see if my diet is now meeting all requirements and have a recap for race day nutrition with food and fluid.”

References 1 B Thomas and BDA, 3rd edition (2001). Manual of Dietetic Practice, Oxford 2 A Pocket Guide to Clinical Nutrition (2011), 4th edition, the PEN Group, British Dietetic Association, BDA, Birmingham 3 Joint position statement: Academy of Nutrition and Dietetics (formerly American Dietetic Association) Dietitians of Canada, American college of sports medicine (2009) Nutrition and athletic performance. Advancing health through food and nutrition. Pdf-position-paper.pdf (accessed12th January 2016) 4 www.bda.uk.com/foodfacts/home/sports food facts pdf by Linia Patel RD (accessed 9th January 2016) 5 www.nhs.uk/Livewell/Goodfood/Pages/Fat.aspx (accessed 9th January 2016) 6 DOH (1991), 41 Dietary Reference values for food energy and nutrients for the United Kingdom, The Stationery office, Norwich, UK 7 European Food Safety Authority (2010). Scientific opinion on dietary reference values for water, EFSA Journal 8: pg 1459 8 www.Nutrimen.co.uk (accessed 9th January 2016) 9 Benadot D (2012), 2nd edition, Advanced Sports Nutrition, Sheridan Press, USA 10 www.gov.uk/government/uploads/SACN_Carbohydrates_and_Health.pdf (accessed 9th January 2016) 11 McCarthy EK and Kiely M (2015). Vitamin D and muscle strength throughout the life course: a review of epidemiological and intervention studies. Journal of human Nutrition and Diet, 28, pg 636-645, doi:10.1111/jhn.12268 12 www.gov.uk/SACN_Vitamin_D_and_Health_Report.pdf (accessed 9th January 2016) 13 MAFF (1996), 10th edition, Manual of Nutrition, The Stationery office, Norwich, UK 14 www.theguardian.com/uk-news/2015/aug/16/washout-british-summer-witness-holiday-experts (accessed 9th January 2016) 15 Bates B et al (2014). National Diet and Nutrition survey. Results from years 1-4 (combined) of the rolling programme (2008/2009-2011/12), London: Public Health England 16 Spiro A and Buttriss J (2014). Vitamin D and overview of vitamin D status and intake in Europe, Nutrition Bulletin 39: pg 322-350 17 Patel L (2013) Eat drink and recover - The basics of sports nutrition recovery, Dietetics Today, May 2013: vol 39, No 5, pg 30-32 18 Rang H P et al (1996), 3rd Edition, Pharmacology, Churchill Livingstone, London, UK 19 Foods Standard Agency (2003). Safe upper levels for vitamins and minerals, available at http://cot.food.gov.uk/sites/default/files/vitmin2003.pdf (accessed 9th January 2016) 20 Padden-Jones et al (2008). Role of dietary protein in the sarcopenia of ageing, American Journal of Clinical Nutrition, 87 (supplement) 1562s-6s 21 Matt Fitzgerald (2013). The new rules of marathon and half marathon nutrition, Boston, USA 22 www.jissn.com/content/7/1/7 (electronic version). ISSN exercise & sport nutrition review: research and recommendations, Journal of the International Society of Sports Nutrition 2010, 7:7, accessed 9th January 2016 23 Economos CD et al (1993). Sports medicine, Nutritional practices of elite athletes. Practical recommendations, Dec 16 (6) 381-399

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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

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. 28

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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

DYSPHAGIA: what every dietitian MUST know about thickeners Sheri Taylor Registered Dietitian, at Eat Great Feel Great, SSOTP/East Staffs CCG Sheri has been a Registered Dietitian for over 20 years and specialises in mindful eating, taste and smell disorders and texture modified food. She is director of Eat Great Feel Great (www. eatgreatfeelgreat. co.uk) and provides nutrition support at SSOTP/ East Staffs.

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

Thickeners are ACBS prescribable powders, made from starch and/or gum, used to alter the viscosity of food and fluid.1 Thickeners are used by people with dysphagia (difficulty swallowing) to slow the transit time of food and fluid in the mouth and pharynx which helps coordinate the swallowing process; this makes the bolus safer to swallow.1,2 Here, Sheri Taylor provides essential information on thickeners, the products available, how to mix them and also gives us insight into her own understanding of her clientsâ&#x20AC;&#x2122; experiences. A speech and language therapist is the one who determines whether or not someone needs thickened fluid and which viscosity is safest for that patient. A bolus thinner than what is recommended by the speech and language therapist can cause aspiration which can lead to chest infections and even death.1 Dietitians should work in partnership with the speech and language therapist and the GP when deciding which thickener to prescribe. The primary goal is to find a thickener that the client finds palata ble and is willing to use consistently. However, there are additional considerations that all dietitians need to be aware of. Here are the top five things that every dietitian needs to know about thickeners: 1. Calories Thickeners contain varying numbers of calories. If a client starts to gain weight shortly after starting on thickened fluid, the thickener itself may be to blame. Of course, the number of extra calories will be contingent on which thickener the patient is on, the viscosity of their drinks and how much fluid they consume each day. For 1500ml of stage 1 fluid, the calorie content of the thickener alone can range anywhere from 56-263 calories per day. For 1500ml of stage 3 fluid, the calorie content jumps to 165-504 calories per day. When deciding which thickener to recommend, the multidisciplinary team will need to

consider whether the individual wants to gain, lose or maintain his/her weight. 2. Fibre While the traditional starch-based thickeners do not contain any fibre, the newer gum-based thickeners can contribute quite significant levels of soluble fibre to someoneâ&#x20AC;&#x2122;s diet. For some patients, the extra fibre might be helpful. For others, the soluble fibre has the potential to reduce satiety,3 cause loose stools, contribute to abdominal discomfort and/or lead to significant gas production.4 Be aware of this in clients with learning disabilities, dementia or others who may not be able to communicate when they are in discomfort. 3. Carbohydrates Starch-based thickeners will contribute the highest levels of carbohydrate to the diet. Thickening 1500ml of fluid with a starch-based thickener will provide 51-131 grams of carbohydrate per day (depending on the viscosity and the brand of thickener used). These carbohydrates will generally be distributed throughout the day, as small amounts are added to each drink and possibly pureed food as well. Be cautious, however, if someone consumes large amounts of thickened fluid (and/or pureed food) in a short space of time; for example, someone who needs assistance with eating and drinking and who only gets domiciliary carer visits four times daily. www.NHDmag.com March 2016 - Issue 112

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 patientâ&#x20AC;&#x2122;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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New Purée Petite. 500+ calories and 15g+ protein in one smaller portion. Perfect for reduced appetites. NEW RANGE

647 - Purée Petite Salmon Supreme

The new Purée Petite range takes a fresh look at Category C meals, for patients with dysphagia. Each energy-dense 275g dish is smaller in size for patients with reduced appetites, but with similar calorie and protein content to the larger meals in our Softer Foods range. Meaning the much needed nutrition goes exactly where it belongs, in your patient. Arrange a free tasting today and discover how Purée Petite and our other Softer Foods meals for Category C, D and E diets can help your patients.

To order a FREE brochure or to arrange a tasting call

0800 066 3169 wiltshirefarmfoods.com

Softer Foods from

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

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

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• 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 BDAâ&#x20AC;&#x2122;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 personâ&#x20AC;&#x2122;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

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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ENEFITS IONALTBOGHURT NUTRIT EOVNFIT ERAL F Y FOLLOAP EEDING AIN WMIN EGDDSIN IATTRPORK GNA RIC EE NCY FO OD AL LE RG Y ISSN 1756-9 567 (Online)

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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

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

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 â&#x20AC;&#x2DC;precision medicinesâ&#x20AC;&#x2122;, 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

21.4

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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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 patientâ&#x20AC;&#x2122;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 patientsâ&#x20AC;&#x2122; 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)

â&#x2030;Ľ16 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)

Jejunal TPN

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

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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

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 patientâ&#x20AC;&#x2122;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

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

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

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, â&#x20AC;&#x153;You are so slim and beautiful/handsome, how do you do it?â&#x20AC;? 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? Todayâ&#x20AC;&#x2122;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

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 childrenâ&#x20AC;&#x2122;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 â&#x20AC;&#x2DC;Juvela Clubâ&#x20AC;&#x2122; 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 UKâ&#x20AC;&#x2122;s largest dietetic jobsite since 2009

CAREER

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We urgently require dietitians for immediate vacancies s

â&#x20AC;˘ Quarter page to full page â&#x20AC;˘ Premier & Universal placement job listings â&#x20AC;˘ 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

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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

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

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

www.NHDmag.com March 2016 - Issue 112

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

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

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 â&#x20AC;&#x2DC;springâ&#x20AC;&#x2122;. 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 veteransâ&#x20AC;&#x2122; 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

EXTRA

The Magazine for Dietitians, Nutritionists and Healthcare Professionals

20 16

NHDmag.com

March 2016: Issue 112

NUTRITION AND DIETETICS IN

TANZANIA Thoughts on Casual Dining by Ursula Arens

Norma Lauder remembers Pat Torrens

NHD-Extra: PUBLIC HEALTH

Nutrition in Tanzania Zohra Lukmanji Registered Dietitian After training as a Dietitian and short work spell in the UK, Zohra, a Tanzanian national, returned to her home in 1978 to work with the Tanzania Food and Nutrition centre. Since then, her work in nutrition and dietetics in development, emergencies and academia, within and outside of Tanzania, has been diverse. She acquired her MSc in Community Nutrition at the University of Queensland in Australia.

Tanzania is dietitian Zohra Lukmanjiâ&#x20AC;&#x2122;s homeland. She works in many dietetic areas in the country, helping to support nutritional advances and developments. Here she gives an overview of Tanzaniaâ&#x20AC;&#x2122;s nutritional status, needs and requirements, as well as the interventions that have already been put in place. Tanzania, also known as the land of Kilimanjaro (the highest mountain in Africa), is the 31st largest country in the world and the largest country in East Africa. It borders the Indian Ocean to the east and has land borders with eight countries: (anti-clockwise from the north) Kenya, Uganda, Rwanda, Burundi, the Democratic Republic of Congo (across Lake Tanganyika), Zambia, Malawi and Mozambique. The country includes Zanzibar (consisting of the main island Unguja, plus Pemba and other smaller islands). Dodoma is the political capital of Tanzania and Dar es Salaam (DSM) is the largest city and the principal commercial capital

Figure 1: Geographical and Administrative maps of Tanzania

www.NHDmag.com March 2016 - Issue 112

Tanzania is one of the poorest countries in the world, with the United Nations classifying it as one of the least developed countries. Its population of 51.82 million (2014) is diverse, composed of several ethnic, linguistic and religious groups. Urban population accounts for more than 25%, 7% of which live in urban agglomerations of more than a million people. The population annual growth rate stood at 2.8% (20141 estimated). Average life expectancy in 2012 was 61 years (51 in 1990). Disease burden

The burden of diseases in Tanzania is high, with communicable diseases still

Overall, urban children are more likely to enjoy better nutrition than rural children; accordingly 31.5% of urban children below five years were stunted, compared with 44.5% of rural children. prevailing. Communicable, maternal, perinatal and nutritional conditions account for 65% of total deaths in all ages. HIV/AIDS, tuberculosis and malaria, all with nutrition implications, are among the most important. Increasingly, the country is confronted with the ‘double burden of disease’ due to noncommunicable diseases which are estimated to account for 27% of all deaths and the remaining 8% of deaths occur due to injuries (World Bank, 2008; WHO NCD). The prevalence of HIV/AIDS as estimated in 2012 was 5.1%, lower than that reported at 7% in 2008 (World Bank), and was higher among women than men (7% and 5%, respectively). Tanzania is one of the 22 high burden countries for TB prevalence. The TB mortality rate (excluding HIV) is 13 per 100,000 populations; its prevalence is estimated at 183 per 100,000 populations (WHO TB). However, its treatment success rate has reached the WHO global TB control target of 85%. More than 50% of TB patients in the country are co-infected with HIV (WHO Cooperation). Malaria is a leading public health problem and cause of death in 36% of all deaths in children under-five in the mainland and accounts for about 40% of total OPD attendance. However, in Zanzibar, since the scaling-up of multiple interventions, including Long-Lasting InsecticideTreated Nets (LLINs) to vulnerable groups and the deployment of Indoor Residual Spraying (IRS), malaria is no longer the number one cause of child mortality (WHO Cooperation). Non-communicable diseases (NCDs) are on the rise in Tanzania, particularly in the urban areas, where more than 25% of the population resides (WHO Cooperation). According to 2008 data, the total number of deaths due to NCDs was 757,000 among males and 588,000 among females. Out of this number, 42.8% of

all deaths in males and 28.5% of all deaths in females under age 60 are due to NCDs (WHO Tanzania website). Diabetes prevalence is reported to be high in the urban Tanzanian community where prevalence of overweight is also growing (Aspray et al 2000). Nutrition status

Tanzania has been at the forefront in promoting multidisciplinary2 nutrition interventions through its national institution, the Tanzania Food and Nutrition Centre (TFNC) since 1977. Tanzania has made progress in reducing undernutrition in children under five since 1991. Despite progress made, however, malnutrition remains one of the most serious health problems affecting infants, children and women of reproductive age. Major problems such as one or more forms of undernutrition, including low birth weight, stunting, underweight, wasting, anaemia, iodine and vitamin A deficiency, still persist. According to data3 from the Tanzania Demographic and Health Survey (TDHS)4 2009/10, child underweight5 was 16% (27% in 1996) and stunting6 was 42% (48% in1996). Nevertheless, the prevalence of child underweight and stunting in 2010 was still unacceptably ‘high’ according to criteria of the World Health Organisation (WHO, 1995). Wasting (low weight for height)7 was prevalent among 4.8% under-fives (2010) Overall, urban children are more likely to enjoy better nutrition than rural children; accordingly 31.5% of urban children below five years were stunted, compared with 44.5% of rural children.8 Malnutrition is associated with 56% of childhood mortality losses of up to 13% of intelligence1 in Tanzania.9 Stunting in early childhood is usually associated with poor development in young children, and delayed neurosensory integration, low IQ and school achievement in older children.10 The percentage of children above +2 SD for weight for height (overweight) was 5%; urban 5.8% and rural 4.9%, and although low it is likely to increase. Vitamin A, iron and iodine deficiencies are also prevalent in Tanzania. According to the TDHS 2009/10, national prevalence of vitamin A deficiency was 33% among children under five years of age; approximately two-thirds of children had iron deficiency. The same survey indicated that just over half the households consumed salt www.NHDmag.com March 2016 - Issue 112

NHD-extra: PUBLIC HEALTH Table 1 Area

BMI less than 18.5 (kg/m2)

BMI greater than 18.5 (kg/m2)

Urban

36%

Rural

13%

15%

which was adequately iodized. This, interestingly enough, correlated with mother’s education and high income households (HHs). Women

According to TDHS survey 2010, 11.4% of women age 15-49 years were reported to be thin (BMI <18.5kg/m2). Those having BMI of 25 or more was just over 20%, which is five times more than that reported in 1991. The women in the highest income group were most affected (41% as compared with most affected poorest 8%). Overall, the survey indicated a lower proportion of thin women than the overweight/obese women (Table 1). The urban vs rural difference in the proportion of women with BMI less (8% vs 13%) and more than 18.5 (36% vs 15%) were also noted. Forty four percent of women in Dar es salaam, the city with the most urbanised population, were reported to be overweight/obese and this cuts right across all socio-economic groups of the population. Almost two-thirds of these women have no concept of their nutritional status. Overall, national prevalence of obesity among adult population (25 years and over) was 5% in 2008 (CIA world factbook). Interestingly, less than 3% of the Tanzanian adults, age 25-64 years11 consume fruit and vegetables as per WHO recommendations of five servings and 400g/day. School children

At national level, there is no data available on the nutritional status of school children age six to 15 years. The data from ad hoc surveys carried out in specific urban and rural areas clearly indicated the existence of underweight, ranging from 2050% and an increasing trend of overweight and obesity (specific to urban areas 9-22%). The proportion of malnourished children has reduced since 1991, but the overall calorie intake has increased marginally since 2001. The diets of the majority remain undiversified, hence increasing 4

www.NHDmag.com March 2016 - Issue 112

the risk of nutrient deficiencies diseases. At the same time, advent of rapidly growing fast food industries (street foods to giant supermarkets) has led to the increasing consumption of processed foods rich in refined sugar and saturated fats, no matter how expensive. The majority have no concept of the ingredients or risk of these foods. The sugary beverages reach even the most remote villages in Tanzania. School children have easier availability of junk foods sold by street vendors or small shops outside of the schools. Agriculture and nutrition status

Agriculture is the main source of employment and livelihood in 77.5% of the rural population. However, for the urban population, agriculture related activities are illegal and, therefore, home gardens are found on any unused land are often at the risk of being evicted. In Dar es Salaam, it is reported that more than 90% of leafy vegetables available in the markets originate in open spaces and home gardens, hence urban agriculture accounts for almost 20-30% HH food supply. In the south and west of the country, surplus food is produced and is known as ‘food basket regions’, but, sadly, there is a relatively high rate of malnutrition. Poverty is pervasive in Tanzania and rural households are disproportionately poor. Not surprisingly, under-nutrition in children is most prevalent among rural households and in the poorest households. According to the TDHS 2010/11, 26% of children in households in the highest wealth quintile were stunted, contrasting with 39-48% in households in the bottom four wealth quintiles. There is a pattern of declining malnutrition with higher income, but several analysts have pointed out that increasing income accounts for only part of the decrease in malnutrition rates.12 Similar results have been found in analyses of the relation between higher national income (GDP) and rates of child malnutrition. Factors other than income alone are clearly at play. Ironically, the same ‘food basket regions’13 and highest wealth quintile HHs were noted to have higher

proportion of overweight under-fives (indicated by weight for height >+2 SD14). The number of children in this category is still at its low level of 5%, similar to children <-2SD). The highest prevalence of HIV in adults, both male and females was observed to be predominant in food basket regions.15 Nutrition interventions

The challenges above have broadly been addressed since the establishment of the TFNC and nutrition interventions have focused on: • prevention of low birth weight • promotion of exclusive breastfeeding • growth monitoring in children below five years • vitamin A supplementation • anaemia control • salt iodation • food fortification • management of severe acute malnutrition • community-based nutrition rehabilitation • immunisation • control of infectious diseases such as diarrhoea, HIV and AIDS • School health • household food security In recent years, the nutrition interventions have been implemented under the three key themes: ‘Scaling up of nutrition’ (SUN), Feed the future and First 1000 days. The implementation of the above interventions has had support from key stakeholders.

UNICEF supported nutrition interventions

UNICEF’s top priority is to ensure that local government authorities genuinely own and effectively lead their work to improve nutrition status. UNICEF’s work includes: • working with district health departments to ensure that they prioritise nutrition and helps them to build their skills in planning, budgeting and coordinating the delivery of nutrition services for children and women; • working with the government to develop an in-service training program for a recently introduced new cadre of nutrition officers16 at district and regional level; • assisting the district health departments in building the skills of health services providers in delivering services to children and women; • working through district health and community development departments, health providers and communities in the field, to help families learn17 essential skills and basic knowledge in the nutritional care of young children; • working with the Ministry of Health and Social Welfare (MoHSW) and with districts to ensure that18 vital nutrition supplies and equipment are available in health facilities.

References 1 Estimates consider the effects of excess mortality due to AIDS; resulting in lower life expectancy, higher infant mortality, higher death rates, lower population growth rates, and changes in the distribution of population by age and sex than would be otherwise 2 National Nutrition Strategy - JULY 2011/12 to JUNE 2015/16 3 National Bureau of Statistics (NBS)[Tanzania] & ICF Macro, 2011 4 2015/2016 DHS recently completed 5 Low weight for age - composite measure of long- and short-term under nutrition 6 Low height for age an indicator of chronic under nutrition 7 Low weight for height an indicator of acute malnutrition 8 Alderman H, Hoogeveen H, Rossi M. Reducing Child Malnutrition in Tanzania: Combined Effects of Income Growth and Program Interventions. World Bank 2007 9 A study in the Kagera region (border Lake Victoria found that malnourished children lose up to two years of education compared to their adequately nourished peers (World Bank, 2007) 10 SM Grantham-McGregor, SP Walker, JH Himes, CA Powell. Stunting and mental development in children. Workshop: Health and functional consequences of stunting 11 Tanzania step survey - 2012 - Fact sheet 12 Mkenda A. The Benefits of Malnutrition Interventions: Empirical Evidence and Lessons to Tanzania, Report for the World Bank, 2004 13 3 regions - Rukwa, Mbeya and Iringa in Southern Tanzania (Figure 1) 14 Expressed in standard deviation (SD) from the median of the WHO child growth standards 2006 15 Tanzania HIV and AIDS and Malaria Indicator Survey 2007-08 16 None with formal dietetic qualifications or academic background - up until now a handful in the country and those recently qualified and employed 17 This includes best practices in breastfeeding and complementary feeding, the promotion of iodized salt consumption and health-seeking behaviour 18 1including vitamin A supplements, deworming tablets, highly nutritious therapeutic foods to treat severe acute malnutrition, and equipment to measure nutrition status

www.NHDmag.com March 2016 - Issue 112

NHD-Extra: WEIGHT management

CASUAL THOUGHTS ON CASUAL DINING 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

In late February, more than 170 companies exhibited at the ‘Casual Dining’ show at the Business Design Centre in Islington. Every kind of food and drink supplier to the eating-fast trade was there. Food choice has never been wider, and food speed has never been faster, says Ursula Arens. Of course there was excitement and buzz at the Casual Dining show, because the sector is booming. This is less because of the genius of beguiling products on offer, but rather because the sector offers the perfect match to the siren calls of time-poor consumers, burdened with declining skills in the kitchen and the demands of screenenslavement*. Fast-and-easy is the food solution most highly valued by consumers of today. In fact, Islington residents even have trouble leaving the sofa to go out to eat at restaurants or takeaways; restaurant collection scooters are everywhere. The ‘Just Eat’ delivery service had an increase in revenue in the year to 2015 by nearly 60% to £248 million and nearly 65 thousand restaurants are now ‘on call’ through their mobile phone app. Food choice has never been wider, and food speed has never been faster. So, what where the diet or nutrition themes revealed at Casual Dining? Star foods are still the twin offspring of the low carb craze: coconut and avocado. A coconut flavour vodka drink won the new products competition, but even as the award was announced, the developer stated that the sample product was going to be changed: 128 calories in the 250ml bottle was creating anxiety in the young female target, and reformulation is planned to allow ‘only 99 calories’ per serving claims on labelling. Another competition winner was frozen ready-to-serve avocado halves, which will allow time-pressed caterers an instant menu update.

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The themes of gluten-free and dairyfree rumble on, and other prizewinners in the new products competition were a dairy-free coconut-based ice cream and gluten-free sweet pastry cases for dessert menus. Gluten-free tags also link hot dogs, myriad pasta shapes and a variety of specialist beers and ales. Flavours are more and more important, but within the strong remit of sugars-with-caution. So, herbal-foradults soft drinks are poised to replace traditional juices and soft drinks and the Japanese Yuzu super citrus is the betting favourite amongst flavorologists. Tea is another booming target for the flavour industry as the British public shows boredom for the straight brew and black tea, plus was very evident in the displays (which means plus, for example, bubble gum or butterscotch or chocolate and nut or elderflower and grapefruit flavours). Allergen anxiety was evident, and several companies offered allergencompliant menu management software systems. Another nice idea was the provision of menu cards for caterers in pubs and restaurants supporting the provision of special diet requests (such as gluten-free). Clearly, the everdemanding customer has resulted in far greater thought and sensitivity to special diet requests, and the greater professionalism in catering for these requirements is a welcome outcome. One stand in particular left me shamefaced. Reynolds is a catering supplier to restaurants and canteens and they had an amazing display of fresh fruits and

Top 10 casual dining brands; turnover, 2015, in £million Pizza Express

406

Frankie & Benny’s

398

Nando’s

395

Harvester

326

Pizza Hut

225

Beefeater Grill

176

Prezzo

175

TGI Fridays

174

Jamie’s Italian

144

Weatherspoon

133

The top 20 brands own 68% of the UK eating-out market

vegetables. But hardly any were familiar to me. White carrots or parsnips? Purple potatoes or beets? A kindly chef talked me though many of the items, with unpronounceable names. But the seed planted is the astonishing variety of vegetables that are theoretically available to customers of today, and the possibility that veg-expertise could become as acclaimed as wine-expertise in culinary elites…which hopefully could contribute to a wider sourcing and consumption in supermarket shoppers, in the way that wine has in the past few decades. The questions dietitians may ask is whether veg-snobbism is a help or hindrance in greater total intakes in the UK population. CEOs of companies such as Wagamama, Gourmet Burger Kitchen and Carluccio’s gave presentations on how they saw the future (= rosy). Success was all about identifying the ‘sweet spot’ between the triangle of speedy service, quality interesting foods and perceived-value prices. Most eater-outers preferred international cuisine to classic English/British menus, and Italian, Indian and Chinese were still the favourites. Casual Dining providers needed to assess their offerings in relation to time of day and age groupings, to keep interest and custom, and (yawn) the importance of digital marketing was the common theme: “email does not cut it anymore.” A report commissioned by the company Sacla Italia provided data from in-depth interviews with more than 2,000 consumers. Eating-out

occasions were described to be increasingly fluid, flexible and informal - something that was termed, the deregulation of life. Of interest to dietitians was that one of the 10 ‘certainties’ about the future, was the greater focus by consumers on optimising individual health and wellness: this would become mainstream (or mandatory). Also in the conclusions section of the report of seven do-immediately actions for Casual Dining providers, was to explore health partnerships, as this would continue to be a constant theme of consumer interests. Jobs for dietitians. Every retailer knows that the customer always wants it all, and is always right (or they are not your customer). The main themes of the show that water must be coconut, pasta must be gluten-free and pork must be pulled, do not really fit in with current public health messages, but clearly the Casual Dining sector is sensitive and responsive to perceived health concerns; the only problem is one of translation, as nutrition messages via media and customers are mixed and muddled. There is a great urgency for some pragmatic and trend-aware dietitians to join this sector as friends-not-foe. A few inside wins could do much to steer decisions towards a healthier diet for the population, and no profession is better placed to make a much-needed impact. A diary date for interested dietitians is the next Casual Dining show in Islington, London on 22-23 February 2017.

* Average UK adult spends over eight hours a day (521 minutes) on screen-based activity (smartphone, TV, tablet, console etc). Reported in trajectory research ‘Eating Out - Today and Tomorrow - the key insights and trends shaping the UK eating-out market’, funded by Sacla Italia.

www.NHDmag.com March 2016 - Issue 112

NHD-Extra: obituary

OBITUARY

Patricia (Pat) Elizabeth Torrens 17th October 1921 to 26th November 2015 Written by Norma Lauder Registered Dietitian, Retired

Norma retired from her role as Head of Nutrition and Dietetics at Doncaster Royal Infirmary in 2010, after 42 years with the Trust. Norma was also Fellow and former Honorary Chairman of the British Dietetics Association (BDA) and was the BDA’s representative on the Whitley P&T ‘A’ Council for NHS employment relations for nearly 20 years.

Pat was brought up in Market Rasen where her father was a GP and Medical Officer at the Racecourse. Her mother had been a nurse before marriage, but had decided, with Pat in agreement, that Nursing was not for her daughter. However, Pat’s mother had heard of the newly emerging profession of Dietetics and after enquiries, Pat went off to train, firstly at the Edinburgh and East of Scotland College of Domestic Science (Athol Crescent), and then at the Royal Infirmary of Edinburgh, qualifying in 1942. After a period working in Catering, Pat moved to the Westminster Hospital as a dietitian in 1951, becoming Chief Dietitian, a post she held until 1972 when she became the first full-time Dietetic Adviser to the Department of Health. Previously, there had been Catering Advisers who were also dietitians, but this post made Dietetics unique among the Allied Health Professions in having its own professional adviser, a post she held with distinction until her retirement in 1984.

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As preparations were made for the first reorganisation of the Health Service in 1974, Pat, as a member of the BDA’s Progress and Development Committee, worked hard to ensure that a new viable structure for the profession would emerge, creating the post of District Dietitian. This saw the profession expand from the mainly hospital/clinical sphere, (there had been a very few Community Dietitians in the 60s and early 70s), to become the profession we would recognise today with its broad input into Clinical, Community and Public Health. Crucially, recognising that senior members of the profession needed to make a huge transition in knowledge and skills if they were to be successful in filling these posts, Pat obtained the resources from the Department of Health to run role development courses at the NHS Training Centre in Harrogate for all the newly appointed District Dietitians. Some other senior members of the profession had been sceptical of their colleague’s ability to make the transition to the wider

sphere of influence, but the courses led the way, enabling dietitians who had worked for many years to take on and successfully develop new ideas for the delivery of dietetic services. As Dietetic Adviser, Pat travelled extensively, giving advice and support to both local management and their dietetic staff. She sat on the management side of the P&T ‘A’ Whitley Council, respected by both sides, steering a balance between the needs of the service and the aspirations of the profession. Pat was a supportive colleague and many remember her nodding in agreement with them as they spoke at meetings. She was also great fun to be with, enjoying food and company, always travelling with The Good Food Guide in case of emergency. Both management and staff had cause to be grateful for this during one not-to-be-forgotten joint visit to Glasgow when she rescued us from a miserable situation by producing the Guide, enabling us to have a convivial evening between two very trying days. For many reading this, it will be difficult to remember the women of Pat’s generation, who in the first world war lost the men who would have gone on to be husbands. Pat never repined, becoming instead a devoted Godmother whose Godchildren remember her with affection and gratitude. She provided

them with experiences, some must have been very hard to organise, which they remember with a smile. Pat’s father’s links to the Market Rasen Racecourse meant that she enjoyed horseracing throughout her life, preferring National Hunt and Three-Day events like Burghley. I have happy memories of a bitterly cold January day at the course, when a Hip flask of Cherry Brandy was produced to keep out the cold. She travelled extensively with friends and maintained lifelong friendships. Pat held office in the British Dietetic Association as Hon Secretary (1963-67), then Chairman between 1968 and 1970 and was made a Fellow in 1979. In retirement, Pat became Church Treasurer for a number of years and volunteered in a local charity, the Ham and Petersham SOS which supports the elderly and who in turn supported her in recent months. She continued to drive into her 90s, but latterly her arthritis became very troublesome. She refused to take painkillers on a regular basis, living independently in her home of many years, but and as she said to her beloved Goddaughter Jane, ‘it was time to move on’. There can be few dietitians who touched the lives and careers of so many other dietitians.

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