NHD April 2016 issue 113

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

NHDmag.com

April 2016: Issue 113

food labelling Guidelines cows’ milk allergy Goat milk: an alternative ulcerative Colitis glycogen storage disease

Ancient Grains in the modern diet

THIS IS HUGE After months of coping with the sleepless worry and heartbreaking cries of his cow’s milk allergy, suddenly, a little moment like this doesn’t seem so little after all.

• Proven efficacy – hypoallergenic and has been shown to relieve symptoms1,2 • Proven to be well tolerated – 96% of infants tolerated Similac Alimentum3 • Palm oil and palm olein oil free – supports calcium absorption and bone mineralisation4 SIMILAC ALIMENTUM. FOR BIG LITTLE MOMENTS.

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

IMPORTANT NOTICE: Breastfeeding is best for babies, and is recommended for as long as possible during infancy.

Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional.

Date of preparation: July 2015 RXANI150143

FROM THE EDITOR

welcome Emma Coates NHD 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.

It has been an exciting few weeks for Dietetics, with the announcement in February of supplementary prescribing rights for dietitians by George Freeman, Minister for Life Sciences. Advanced and experienced dietitians can manage prescribing for patients without the need for medical staff approval . . .

Neil Donnelly discusses this historical development in our Final Helping.

However, before you flip from this warm Welcome to Neil’s final tasty morsel, have a look at our sumptuous filling.

Maeve Hanan’s first article for NHD explores the forthcoming EU regulations and UK guidelines for food labelling.

Maeve guides us through the key points, including alterations to the nutritional declarations on packaging, health claims, allergen and front of pack information.

Following on from that, we have an excellent cows’ milk protein allergy (CMPA) feature from Dr Rosan Meyer, Paediatric Allergy Dietitian at GOSH. Rosan looks at the current guidelines for this condition and questions whether they support healthcare professionals in achieving better diagnosis and management of CMPA. CMPA is also touched on by Specialist Paediatric Dietitian Jacqui Lowdon in her article discussing goat milk and the evidence for its use as a cows’ milk alternative feed for infants. Historically, infant formulae based on cows’ milk were the mainstay of infant feeding when breastfeeding was not possible, or breast milk supply was insufficient. Recently goat milk has been approved as an alternative source for infant formulae.

Continuing the theme of alternative food options, Gemma Sampson RD offers us a plateful of ancient grains and asks if they are a real alternative to conventional cereals. She takes us through the current thinking about their nutritional properties, health benefits and their position in the modern diet.

I have contributed with a two-part article, which follows a case study of an 18-year-old female with Ulcerative Colitis and discuss its impact on the young woman’s nutritional status and general wellbeing. Part 1 is featured in this issue and you can access Part 2 via the Subscriber’s Zone at www.NHDmag.com. Logon with your password to view Part 2 and a host of other subscriber resources. If you don’t have login details, check whether you are eligible for a free subscription to NHD from our homepage.

IMD Watch this month focuses on Glycogen Storage Disease (GSD) type 1, with Freelance Paediatric Dietitian, Rychelle Winstone giving us a valuable overview of the condition, along with its treatment and management.

In addition to all of these great features, Ursula Arens asks whether our choice of drinks and beverages has an impact on our eating habits. Does drinking more mean eating more?

Alternatively, do some drinks make you eat less? Ursula helps to untangle the complex issue of ‘drinks links’.

Finally, our PENG column encourages dietitians to engage in research and audit activities to improve clinically effective practice. Jacklyn Jones, talks us through PENG’s aims and initiatives to support dietitians in taking the first steps into research and audit activities through a recent study day with workshops, mentoring and the availability of small project grants.

Enjoy the read - Emma www.NHDmag.com April 2016 - Issue 113

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Contents

11 COVER STORY

Food labelling guidelines update 3

Welcome . . .

6

News

8

Choice-chains

41 Ancient grains

From the NHD Editor

In the modern diet

Latest industry and product updates

46 On behalf of PENG

Does drinking more mean eating more?

Research and audit

17 Cows’ milk protein allergy

Is the message getting through?

49 Web watch

Online resources and updates

23 Goat Milk

50 dieteticJOBS

Latest career opportunities

An alternative infant feed

50 Events and courses

Upcoming dates for your diary

29 IMD watch

Glycogen storage disease type I 35 Case study: ulcerative colitis

The impact of IBD on an 18-year-old

51 The final helping

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

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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 April 2016 - Issue 113

ISSN 1756-9567 (Print)

Kcal Protein

400 20g Vits & Mins Fibre

50% 0 g RNI

NEW

FORTISIP 2kcal A DOSE OF SUNSHINE

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*RNI for males 19–50 years used as a comparator (excluding sodium, potassium, chloride and magnesium). †ƐƏ ੿] b|-lbm r;u ƑƏƏ lѴ 0o Ѵ;ĺ ‡Ensure TwoCal (3.4 µg) and Fresubin 2kcal (5 µg) Ő1ouu;1| -| ঞ l; o= ru;r-u-ঞ omőĺ Date of preparation: 03/16

NEWS

FOOD FOR THOUGHT

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

Latest on sugar and salt New sugar tax It has been unveiled by George Osborne this month that there will be a sugar tax in the new budget. The levy which targets soft drinks will use proceedings to fund school sports. This is a great step forward but also needs to be supported by new food and beverage labelling schemes. Currently labels use ‘total sugars’ rather than ‘free’ or ‘added’ sugars which can lead to confusion when comparing against the latest Scientific Advisory on Committee sugar guidelines (as we have seen with the Change4Life Sugar Smart app). Alignment of these is fundamental if guidelines are to be translated into public practice. (Turn to page 11 for more on food labelling guidelines).

New sodium report The National Diet and Nutrition Survey has also now published results from the Urinary Sodium Survey. This has estimated salt intake in adults aged 19-64 years in adults in England. The report also presents a trend analysis for salt from 2005/6 to 2014.

Overall, the latest report shows that mean salt intakes for men and women aged 19 to 64 years are 8.0g and 6.8 grams per day, respectively. So it can be seen that these are 33% and 27% higher than the SACN recommendation - that the average salt intake of the population should be no more than 6.0g per day.

So, more work to be done here too, especially amongst males.

For more information, see: www.gov.uk/government/statistics/national-diet-and-nutrition-survey-assessmentof-dietary-sodium-in-adults-in-england-2014

Organic food - better nutritionally?

Organic food options are when looking at data from all livestock, becoming an increasingly it was found that total PUFA and popular lifestyle choice. Now, omega-3 PUFAs were 23% and 47% two new meta-analysis papers higher in organic meat, respectively. have looked at whether The same team of scientists also organic meat and milk really looked at 170 papers comparing organic are better from a nutritional and conventional cows’ milk. Once stance. again, total PUFA was 7% and omega-3 Scientists’ pooled data from 67 PUFA levels 56% higher in organic milk. separate studies, all looking at the Organic milk also had significantly nutritional composition of organic higher α-tocopherol and iron levels, but and non-organic meats. Meats studied lower amounts of iodine and selenium. included pork, beef, chicken, turkey, Overall, it can be seen that organic lamb, goat or rabbit. Generic searches meat and milk appear to have a more were also carried out using the terms desirable fatty acid composition. This ‘livestock’, ‘meat’ and ‘poultry’. seems to be due to grazing and forage For meat, differences between based diets typically followed under individual fatty acids and micronutrient organic standards. profiles did not produce any meaningful For more information see: Średnicka-Tober D et al results. This was due to the quality of (2016). British Journal of Nutrition Vol 115, no 6; pg studies not being sufficient. However, 994-1011 and pg 1043-60.

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Product / Industry News Inositol for NTD prevention?

There has been much interest in folic acid (FA) fortification recently, in order to prevent neural tube defect (NTD) occurrence. It is also recognised that vitamin B12 can help reduce NTD risk and now work is looking into the role of inositol, another member of the B vitamin family.

The PONTI (Prevention of Neural Tube Defects by Inositol) study randomised 47 women to take a supplement containing inositol +FA in the peri-conceptual period, or a placebo +FA. Overall, 33 pregnancies occurred with one NTD affected pregnancy in the placebo +FA group, but none in the inositol +FA group. There were no adverse pregnancy outcomes in the inositol group.

Clearly, this was a small pilot study. That said, mechanistic studies and larger scale interventions focusing on the role of inositol could be worthy of investigation.

Wiltshire Farm Foods launches new range of Free From meals Each of the new 13 delicious dishes in the Free From range are free from the following allergens: gluten, milk (and other related dairy products), egg, nuts, peanuts, fish, crustaceans, lupin, molluscs, sesame, sulphites and celery - meaning your patients can enjoy every meal, whatever their dietary requirements.

To order brochures or arrange a free tasting of the NEW Free From range, visit www.wiltshirefarmfoods.com

To book your Company’s product news for the next issue of NHD Magazine call 0845 450 2125

For more information, see: Greene ND et al (2016). British

Journal of Nutrition Vol 115, no 6; pg 974-83.

Capsaicin - satiety due to GI distress?

Well, whilst it was beginning to emerge that red chillies could be one way to kick start satiety and lower energy intake, new research pinpoints that there could be other reasons behind this.

The research published in The American Journal of Clinical Nutrition studied the effects of a capsaicin (1.5mg pure capsaicin) of placebo infusion fed into the intestine of 13 subjects in a crossover fashion.

It was found that the capsaicin infusion significantly increased satiety but also led to more gastrointestinal symptoms, which included burning, nausea and bloating. Satiety scores also correlated with these sensations.

Levels of gut hormones were unaffected by the capsaicin infusion.

These findings highlight that satiety symptoms reported in past capsaicin studies could be down to the gastrointestinal stresses they cause rather than changes in appetite hormones.

Anthocyanins and lung function While dietary flavonoids have been known to have antioxidative and anti-inflammatory effects, it is largely unknown whether this could help to support lung function.

As part of the Veterans Affairs Normative Ageing Study, a follow-through study measured lung function along with flavonoid intakes of 839 elderly adults. This was done regularly over a period of 16 years.

It was found that higher anthocyanin intakes were linked to a reduced decline and agerelated lung function. This trend was observed in both current, former and ‘never’ smokers. In particular, eating ≥2 servings of anthocyanin-rich blueberries per week was found to help support lung function.

These are interesting findings, indicating that anthocyanins could help to support lung function as we age. Now, more work is needed to look into the mechanisms behind this.

Journal of Clinical Nutrition Vol 103, no 2; pg 305-13.

Journal of Clinician Nutrition Vol 103, no 2; pg 542-50.

For more information see: van Avesaat M et al (2016). American

For more information see: Mehta AJ et al (2016). American

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WEIGHT management

CHOICE-CHAINS 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 Information Sources: An R (2016).

Beverage Consumption in Relation to Discretionary Food intake and Diet Quality among US Adults, 2003 to 2012.

Journal of the Academy of Nutrition and Dietetics 116, 28-37

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Does drinking more mean eating more? Or do some drinks make you eat less? These questions of food and drink choice-chains need statistical uncoupling by measuring the gradients of population diet and drink intake patterns over time.

Thank goodness Professor Ruopeng An has both the brains and the stomach to unweave this messy tangle of dietary connections. His excellent analysis of drinks-links is presented in the January issue of The Journal of the Academy of Nutrition and Dietetics (An, 2016).

It seems that consumers of diet beverages and sugar-sweetened beverages (SSBs) are different not just in their drinks choices: they also make different food choices. And this is also the case for drinkers of coffee or alcohol. What you drink may couple with what you eat.

Of course, coffee-and-cake or beer-andcrisps are matches: drinking coffee with crisps or beer with cake seem bizarre combinations. So would it be reasonable to predict that coffee drinkers consume more cake=sugars and beer-drinkers consume more crisps=salt?

Professor An examined beverage choices of more than 22,500 American adults from data collected from the National Health and Nutrition Examination Survey (NHANES), in the years 2003 to 2012. Two non-consecutive day intakes were assessed to give two-day average scores. What do American adults drink? Most (53%) had coffee, which was twice as likely a choice as tea (26%). SSBs were consumed by 43% of the sample, which was twice as likely a choice as diet beverages (21%). Which was very close to the number who had enjoyed one or more alcoholic drinks (22%). Not included within the score system were drink choices of water or milk in any form, or pure fruit juices. The five beverage types

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captured nearly all subjects only 3% reported to be consuming none of these drinks over the two days captured.

In contrast, less than 1% of thirsty respondents reported to be consuming all of these drinks categories.

The next issue was, if you consumed these beverage types, what were the daily kilocalorie contributions from these choices? Alcoholic drinks (beers, wines, liquors, etc) topped the ratings with more than 380kcals. SSBs also added nearly 300kcals to daily energy intakes. Then much lower down the scale, tea drinks provided nearly 70kcals, and coffee and diet beverages contributed tiny amounts of less than 20kcals. Although tea drinks would be expected to match coffee drinks in the UK diet (so, small amounts of energy contributed by additions of sugar and/ or milk), US tea drinking is often iced, sweetened and lemon flavoured, which makes it a more calorific choice than the classic cuppa.

Parallel to data on beverage intake, Professor An assessed intakes of discretionary foods. These are described as energy-dense, nutrientpoor food products that are not listed in the main food groups. They are not a necessary part of the diet, but can add diversity, and may be useful in small amounts by those who are physically active. Alphabetical examples include: cakes, chips, chocolates, cookies, fries, ice cream, muffins pies, popcorn and

Choosing to drink alcohol was again linked to the largest increase in energy intakes by more than 380kcals.

waffles. There are more than 660 individual foods listed in this category in the NHANES survey form and, of course, most people reported consuming some of these foods over two days: on average, more than 480kcals worth daily.

Professor An also assessed overall diet quality scores using the Healthy Eating Index score (which matches diet intakes with the US national healthy eating guidelines). The average score was just under 50%, but interesting that weekday scores were 10 points better than weekend scores.

This is another of many examples of food survey data showing differences in weekday versus weekend patterns, and the need to include weightings for this in the analysis of data.

There were some associations between beverage choices and total daily intakes of energy.

Choosing to drink alcohol was again linked to the largest increase in energy intakes by more than 380kcals. SSBs boosted total energy intakes by more than 220kcals per day. Choices of coffee or of diet drinks or tea were linked to energy intakes of just over or 100kcals or less. The most interesting pattern was that choices of alcohol or tea resulted in energy intakes that matched beverage choice. So, for example, people who chose alcohol obtained about 380kcals from this source and total daily energy intakes increased by this amount. In contrast, diet drink or coffee consumers obtained less than 20kcals from their beverage choices and yet their energy intakes increased by 70 and 110kcals respectively. Coffee drinkers appear to consume on average 90kcals

more of other linked foods. Only SSBs showed some substitution effect, so that total energy intakes were slightly lower that those provided directly by SBB consumption.

Looking only at energy intakes specifically from discretionary foods (aka ‘junk’ foods), coffeedrinking resulted in the largest increase daily of 60kcals. SSBs were linked to 30kcals daily and alcohol drinking had the lowest boost effect at about 20kcals. Intakes of energy from associated discretionary foods seem to be in almost perfect beautiful symmetry to the energy intakes from beverages. So, most kcals but least discretionary food intakes come with alcohol drinking, whereas least kcals but most discretionary food intakes are linked to coffee drinking, followed by diet beverages. The association between greater intakes of diet-beverage and greater kcal intakes from discretionary foods was highest in obese adults.

So, coffee-and-cake seems a stronger match than beer-and-crisps (to put picture to the data).

Food and beverage intakes are not a zerosum game and there are compensation and substitution effects. Professor An concludes that healthy eating promotions need to consider the links between beverage choices and other food choices. But the psychology of choice, so that sacrifices demand the balance of reward and compensation, is often observed (“because my latte is skinny, my flapjack can be chocolatecovered”). These and many other aspects of food choice form the daily basis for the wise and supportive advice given by dietitians every day. And Professor An’s research is an excellent contribution to better understanding and supporting those we help. www.NHDmag.com April 2016 - Issue 113

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

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

cover story

FOOD LABELLING: FORTHCOMING EU REGULATION AND UK GUIDELINES Maeve Hanan RD Stroke Specialist Dietitian, City Hospitals Sunderland, NHS

Maeve works as a Stroke Specialist Dietitian in City Hospitals Sunderland. She also runs a blog called Dietetically Speaking.com which promotes evidencebased nutrition and dispels misleading nutrition claims and fad diets.

Food labels are our main means of understanding what our food actually contains; which is really important in enabling us to make more informed and potentially healthier consumer choices. In order to improve the standard of food labelling consistently across Europe, the EU Provision of Food Information for Consumers Regulation1 was adopted in 2011, with most of these legal requirements having become effective on 13th December 2014.

This article examines the implication of this Regulation and, in particular, the ‘nutritional declaration’ aspect which will become mandatory for the majority of food labels from 13th December 2016.

This Regulation sets out three fundamental requirements for food labelling:1 1. Food information shall not be misleading.

2. Food information shall be accurate, clear and easy to understand.

3. Food information shall not suggest that the food prevents, treats or cures a human disease.

MANDATORY INFORMATION FOR FOOD LABELS: (see example, figure 1 overleaf)

a. The name of the food b. The list of ingredients (generally listed in descending order of weight) c. Allergy information d. The quantity of certain ingredients or categories of ingredients e. The net quantity of the food f. The ‘best before’ or the ‘use by’ date g. Any special storage conditions and/ or conditions of use h. The name or business name and address of the food business operator i. The country of origin or ‘place of provenance’ (i.e. when production involves more than one country, this is the country where the primary ingredient comes from, or where the product underwent its last important stage of manufacturing)

j. Instructions for use (where appropriate) k. The alcoholic strength documented as ‘alcohol’ or ‘alc’ followed by the ‘% vol’ (where beverages contain more than 1.2% by volume of alcohol) l. A nutrition declaration Note: Exemptions apply to specific types of glass bottles (only points (a), (c), (e), (f) and (l) are mandatory) and containers where the largest surface area is <10cm2 (only points (a), (c), (e) and (f) are mandatory); however the list of ingredients must be available via other means or upon request. Additional mandatory labelling requirements exist related to products such as: frozen meat or fish, products containing sweeteners, products with a high caffeine content, dried milk products, products in vending machines and alcoholic drinks.

ALLERGEN LABELLING (see example, figure 2 overleaf)

Since 13th December 2014, all products which contain any of the allergenic substances listed below are legally required to clearly specify these in the ingredients list and to highlight these through a typeset distinguished by font, style or colour.1 In cases where there is no ingredients list included, the label must state ‘contains’ followed by the allergens in question; unless the name of the product contains the allergen. www.NHDmag.com April 2016 - Issue 113

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PUBLIC HEALTH Figure 1: Example mandatory information Allergenic substances legally required to be clearly specified in the ingredients list • Cereals containing gluten - wheat, oats, barley, rye, spelt, kamut or their hybridised strains • Crustaceans • Celery • Eggs • Mustard • Fish • Sesame seeds • Peanuts • Molluscs • Nuts - almonds, hazelnuts, walnuts, cashews, pecan nuts, Brazil nuts, pistachio nuts, macadamia nuts & Queensland nuts • Sulphur dioxide and sulphites at concentrations of more than 10mg/kg or 10mg/litre • Soybeans • Lupin QUID: Quantitative Ingredient Declarations source: www.food.gov.uk/sites/default/files/fir-guidance2014.pdf

• Milk

Figure 2: Example allergy information

source: www.reading.ac.uk/foodlaw/label/allergens-guidance-brc-1.pdf

MANDATORY NUTRITIONAL DECLARATION1

From 13th December 2016 a ‘nutrition declaration’ (also referred to as ‘back of pack’ nutritional information) must be present on all food labels.1 Prior to this date (i.e. between 13th December 2011 and 12th December 2016) companies may include a voluntary nutritional declaration which must also comply with the regulation: 12

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a. The energy value declared in both kJ and kcal. b. The amounts of fat, saturated fat, carbohydrate, sugars, protein and salt declared in grams (although it may be stated if the salt content is due to naturally occurring sodium present in the product).

The nutritional content values are legally required to be given per 100g or 100ml; but in addition to this, the nutritional content may also be given: • Per portion or per consumption unit, or • As a percentage per 100g or 100ml (or per portion or consumption unit) in relation to the ‘reference intake of an average adult (8,400kJ/2,000kcal)’ if this is specifically stated. Note: the term ‘Reference Intake’ (RI) is to replace ‘Guideline Daily Amounts’ (GDAs).2

Figure 4: Set order of nutrients for the mandatory nutritional declaration

Figure 3: Example: ‘toffee popcorn’

source: www.bhf.org.uk/publications/healthy-eating-and-drinking/thislabel-could-change-your-life

Food manufacturers may also decide to include some or all of these optional additions to the ‘back of pack’ nutritional declaration: a. monounsaturates b. polyunsaturates c. polyols d. starch e. fibre f. Specific vitamins or minerals when present in ‘significant amounts’ based on Nutrient Reference Values (NRVs) The set order of nutrients for the mandatory nutritional declaration; including the optional additional nutrients and the specified units of measurement is shown in figure 4.

Exemptions from the mandatory nutritional declaration:1 1. Alcoholic drinks containing >1.2% alcohol strength (where it is chosen to include a nutritional declaration it may be limited to the energy value or the energy value with the amounts of fat, saturates, sugars, and

salt. Alternatively, these values may be given on a ‘per portion/per consumption’ unit basis only, rather than per 100g or per 100ml 2. Unprocessed products made of a single ingredient; or where the only processing has been maturing that ingredient 3. Bottled water including those where the only added ingredients are flavourings and/ or carbon dioxide 4. Herbs/spices 5. Salt/salt substitutes 6. Table top sweeteners 7. Certain coffee and chicory extracts, whole or milled coffee beans (including decaffeinated coffee beans) 8. Herbal and fruit infusions, tea, decaffeinated tea 9. Fermented vinegars/vinegar substitutes 10. Flavourings, food additives, processing aids, food enzymes 11. Gelatine, jam setting compounds 12. Yeast 13. Chewing-gums 14. Food labels where the largest surface area is <25cm2 15. Food supplied in small quantities to local retailers directly from the manufacturer (e.g. handcrafted food) www.NHDmag.com April 2016 - Issue 113

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PUBLIC HEALTH ‘PRINCIPLE FIELD OF VISION’ OR ‘FRONT OF PACKAGE’ LABELLING

This refers to all surfaces that can be read from one specific viewing point; but for ease, I will refer to this as ‘front of pack’ (FoP) labelling.

Roughly 80% of processed foods contain some form of FoP labelling.3 As long as the food label contains the mandatory nutrition declaration (i.e. the ‘back of pack’ label), the following information can be repeated on the FoP on a voluntary basis:1 a. The energy value, or b. The energy value and the amounts of fat, saturates, sugars, and salt. In this case, the values given for the nutrients except for energy may be given per portion or per consumption unit only. However, the energy content must be provided per 100g or 100ml as well as per portion or per consumption unit.

Figure 5: Example ‘Front of Package’ labelling

• Portion size expressed in a way which is easily recognisable by, and useful to the consumer, e.g. ¼ of a pie or 1 burger.

• % Reference Intake (RI) based on the amount of each nutrient and energy value in a portion of the food.

• Colour coding of the nutrient content of the food (with an option to include the descriptors ‘High’, ‘Medium’ or ‘Low’ along with the respective colours red, amber or green).

Figure 6: Example standard FoP labelling

source: http://heartresearch.org.uk/heart/green-light-food-labelling

HOW USEFUL DO CONSUMERS FIND FOP FOOD LABELS?

source: www.gov.uk/government/uploads/system/uploads/attachment_ data/file/300886/2902158_FoP_nutrition_2014.pdf

STANDARDISATION OF FoP LABELLING

Despite the finding from the Food Standard Authority in 2009 that ‘standardising to just one label format would enhance use and comprehension of front of package labels’,4 the new nutritional declaration guidelines don’t specify the exact format which should be used for voluntary FoP labelling. Therefore, in June 2013, as a result of a joint consultation held in January 2013 which included input from the main food production stakeholders in the UK,3 a guide was produced outlining the information which should be included on a FoP label:2 • The energy value in kJ and kcal per 100g/100ml and in a specified portion of the product.

• The amounts of: fat, saturated fat, total sugars and salt provided in grams in relation to a specified portion of the product.

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In 2009, the Food Standards Agency released a report on the ‘Comprehension and Use of UK Nutrition Signpost Labelling Schemes’.4 This included a combination of qualitative research (accompanied shops and shopping bag audits) and quantitative research (surveys and interviews, whereby the main survey consisted of 2,932 consumers), which found that a food label which combined text (i.e. ‘high’, ‘medium’ and ‘low’), traffic light colours and %RI was the most user-friendly and bestliked labelling scheme.

This study also indicated that older adults (i.e. those over 65), people with lower levels of education, those from a lower social demographic and certain minority ethnic groups were more likely to have difficulty interpreting FoP labels. Consumers who were shopping for children, those with a medical condition (or a family history of a medical condition), or those trying to lose weight, were found to be more likely to read FoP labels. The main medical conditions identified as having an effect on use of FoP labels were: diabetes, heart disease, hypertension, hypercholesterolemia and coeliac disease. It was found that each group tended to

look at the most relevant nutrients related to their condition; e.g. consumers with diabetes were most likely to check the sugar content.

HEALTH CLAIMS

Although the regulation states that ‘Food information shall not suggest that the food prevents, treats or cures a human disease’, there are some legal exemptions which exist related to foods with particular nutritional uses, such as infant formula. However, if a food supplement claims to have a medicinal effect, it must be licensed under medicines legislation (MHRA).5 Specific nutritional claims which are permitted for use with food products must comply with EU regulations No 1924/20066 and No 1047/2012.7 For example, a food can claim to be ‘low fat’ if it contains no more than 3.0g of fat per 100g for solids or 1.5g of fat per 100ml for liquid; or a food can be marketed as ‘high fibre’ if it contains at least 6.0g of fibre per 100g or at least 3.0g of fibre per 100kcal.6,7 These regulations also set the criteria for the reference ranges used for the traffic light labelling scheme (not including fibre).

Figure 7: Example BHF Food Label Decoder

source: www.bhf.org.uk/publications/healthy-eating-and-drinking/thislabel-could-change-your-life.

SUMMARY OF KEY POINTS

The ‘EU Provision of Food Information for Consumers Regulation’ sets out the legal requirements which food manufacturers must abide by in relation to food labelling. This includes specific guidance on nutritional factors such as allergen information; and from 13th December 2016, it will be mandatory for the majority of food labels to include a specific ‘nutritional declaration’ which includes: the energy content declared in both kJ and kcal and the amounts of fat, saturated fat, carbohydrate, sugars, protein and salt declared per 100g or per 100ml.

As an addition to this mandatory nutritional declaration, food products may also contain a FoP label which includes: the energy value in kJ and kcal per 100g or 100ml and in a specified portion of the product; the amounts of fat, saturated fat, total sugars and salt in relation to a specific portion of the product, the % RI of each nutrient and energy value per portion of the product and traffic light colour coding.

The forthcoming nutritional declaration requirements will hopefully improve the quality, consistency and clarity of food labels to help our patients and the general public make more informed food choices.

References 1 Regulation (EU) 1169/2011 (http://eur-lex.europa.eu/legal-content/EN/ALL/?uri=CELEX%3A32011R1169) 2 Guide to creating a FoP nutrition label for pre-packed products sold through retail outlets (www.gov.uk/government/uploads/system/uploads/ attachment_data/file/300886/2902158_FoP_Nutrition_2014.pdf) 3 FoP Nutrition Labelling: Joint Response to Consultation (www.gov.uk/government/uploads/system/uploads/attachment_data/file/216997/responsenutrition-labelling-consultation.pdf) 4 Comprehension and use of UK nutrition signpost labelling schemes (http://webarchive.nationalarchives.gov.uk/20131104005023/http://www.food.gov. uk/multimedia/pdfs/pmpreport.pdf) 5 Summary information on legislation relating to the sale of food supplements (www.gov.uk/government/uploads/system/uploads/attachment_data/ file/204303/Supplements_Summary__Jan_2012__DH_FINAL.doc.pdf) 6 Regulation (EC) No 1924/2006 (http://eur-lex.europa.eu/legal-content/en/ALL/?uri=CELEX:32006R1924) 7 Regulation (EU) No 1047/2012 (http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32012R1047) 8 Food Labelling in the UK: A Guide to the Legal Requirements (www.reading.ac.uk/foodlaw/label/index2.htm)

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15

For the dietary management of moderate to complex cows’ milk allergy

Making life taste good! with improved

• (QKDQFHG QXWULWLRQDO SURĆOH for improved palatability1,2 • Lower osmolarity from 320 mOsm/l to 300 mOsm/l which may help if malabsorption is present3 • 24.4% MCT decreasing the potential for fat malabsorption • Cost effective to help manage budgets - the most cost effective amino acid formula in the UK4

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References: 1. Alfamino versus Neocate LCP® competitive benchmarking test – Germany 2012 (internal data).2. Alfamino versus Puramino® competitive benchmarking test – UK 2015 (internal data).

3. Shaw, V & Lawson, M. (2007) Nutritional assessment, dietary requirements, feed supplementation. In Clinical Paediatric Dietetics, 3rd edn. eds V. Shaw & M. Lawson, pp 3-20. Oxford: Blackwell Publishing. 4. MIMS January 2016.

Alfamino® is a food for special medical purposes and must only be used under strict medical supervision and after full consideration of the feeding options available, including breastfeeding.

Careline: 0800 0 81 81 80 ROI: 1800 931 832 Email: SMA.Information@uk.nestle.com Website: www.smahcp.co.uk

PAEDIATRIC

Dr Rosan Meyer, Paediatric Allergy Dietitian, Honorary Lecturer, Imperial College London

Dr Rosan Meyer is Principal Research Dietitian within the Gastroenterology Department at Great Ormond Street Hospital.

She is also Research and Education Manager of the Food Allergy and Intolerance Specialist Group of the BDA. Rosan’s areas of expertise include food allergy with special interest in children with food allergies who also have feeding difficulties.

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

Cows’ milk protein allergy guidelines: is the message getting through?

Cows’ milk protein allergy (CMPA) has been shown to be the most common food allergy in infants and young children and, therefore, healthcare professionals need to know current management guidelines to optimally treat children with this allergy.

Several guidelines have been published to help healthcare professionals not only to identify symptoms, but also to guide maternal elimination diets and suitable hypoallergenic formulas for prescription. However, are the messages of these guidelines getting through and are we getting better at the diagnosis and management of CMPA? CMPA can present as either immunoglobulin E (IgE) or non-IgE mediated allergy.1 The main distinctions between these two types of allergy is whether IgE is involved in the pathophysiology and the onset of symptoms. In IgE-mediated CMPA, symptoms occur within two hours of exposure to cows’ milk and nonIgE mediated CMPA symptoms usually set in from two hours and up to a couple of days after the ingestion of cows’ milk.2 In addition to the timing of onset of symptoms, there are distinct differences in the type of symptoms, with IgE-mediated allergy leading to acute skin rashes, facial swelling and in the worst case scenario, cardio-respiratory compromise (called anaphylaxis). Conversely, nonIgE mediated symptoms affect mainly the gastrointestinal tract and skin and can lead to diarrhoea (with/without blood in stool), vomiting, constipation, severe abdominal discomfort and/or atopic dermatitis.3

The recent EuroPrevall data has found that the prevalence of CMPA Europe-wide, based on double blind food challenges, was below 1%.4 From this cohort, the United Kingdom (UK) had one of the highest incidence rates at 1.28%. Following this publication, several researchers have highlighted concerns that the study design may have not adequately identified non- IgE mediated CMPA.5,6 A UK birth cohort study has shown that 2-3% of one- to three-year-olds can be confirmed as having a CMPA, but this still does not adequately reflect the prevalence of non-IgE mediated CMPA. Nevertheless, CMPA has been shown to be the most common food allergy seen in infants and young children and, therefore, healthcare professionals do need to know current management guidelines to optimally treat children with this allergy. www.NHDmag.com April 2016 - Issue 113

17

PAEDIATRIC Table 1: Summary of first line hypoallergenic feed recommendation Clinical presentation Anaphylaxis Acute urticaria or angioedema Atopic eczema/dermatitis Eosinophilic Oesophagitis Gastroesophageal reflux disease Cows’ milk protein-induced enteropathy Food Protein Induced Enterocolitis Syndrome Proctocolitis

MAP guidelines AAF Mild-moderate EHF Severe +/- poor growth AAF Mild-moderate EHF Severe +/- poor growth and/or breastfed top up AAF AAF Mild-moderate EHF Severe +/- poor growth AAF Mild-moderate EHF Severe +/- poor growth AAF

BSACI guidelines* AAF

AAF

AAF

Mild-moderate EHF Severe +/- poor growth AAF

EHF

EHF If requiring a top up formula when breastfed AAF otherwise EHF AAF EHF EHF unless severe in which case AAF

* The BSACI guidelines indicate an AAF formula in any conditions mentioned if food allergies are multiple, growth faltering is present and reactions are severe

Current guidelines

In the last 10 years, 11 guidelines have been published in the English language worldwide on the diagnosis and management of CMPA.2,7-10 Of these, three are from the UK and include the Milk Allergy guidelines for Primary care (MAP),11 the British Society for Allergy and Clinical Immunology (BSACI) guidelines for secondary and tertiary care12 and the National Institute for Clinical Excellence (NICE) Clinical Knowledge Series on CMPA.13 These guidelines in regard to both diagnosis and management are very similar and provide guidance on the diagnosis of CMPA and the management, including information on the maternal elimination during breastfeeding, calcium and vitamin supplementation and hypoallergenic formulas.

For the diagnosis of IgE-mediated CMPA, either skin prick or specific IgE-testing for cows’ milk provides useful support in addition to the allergy focused history, but in primary care, often these tests are not available and healthcare professionals will require to place the child on a cows’ milk elimination diet until supervised challenges or test results are available to confirm the diagnosis.14 For non-IgE mediated CMPA, there is currently no valid test to guide the healthcare professionals to the diagnosis of CMPA and, therefore, a cows’ milk elimination diet with symptom improvement, followed by deterioration with re-introduction, remains the best method for diagnosis.

As the majority of children present in early childhood with this allergy,15 a cows’ milk maternal 18

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elimination diet will be required in breastfed infants. In non-breast fed children, a hypoallergenic formula will be required. A hypoallergenic formula has <1% immunoreactive protein on in vitro testing and should be tolerated by 90% of children with a CMPA (with a 95% confidence interval).16 The MAP and BSACI guidelines both recommend first line choices for a variety of cows’ milk allergic conditions (Table 1). In principle, the guidelines indicate that for the majority of children with mild to moderate IgE/ non-IgE mediated CMPA, an extensively hydrolysed formula (EHF) is appropriate. However, if they have anaphylaxis, faltering growth and/or are exclusively breastfed with symptoms, then an amino acid formula (AAF) is indicated. In addition, if an EHF does not lead to symptom improvement, a trial of an AAF is warranted.11,12 The aforementioned suggestions are well substantiated by published evidence and are in line with international guidelines and the majority of guidelines from other countries.2,17-19 Quality of life for both the family and the child has been associated with symptom severity and foods eliminated and, therefore, is directly linked to optimal dietary management of CMPA.20 Breast milk and/or a hypoallergenic formula contributes to the majority of nutrients in the young infant and, therefore, does not only have an impact on symptoms resolution but also on growth. It is, therefore, important for healthcare professionals to familiarise themselves with formula choices (Table 1).

RELIEVE

REDUCE

REASSURE

cows’ milk allergy symptoms1 with HƯFDF\2

incidence of atopic dermatitis XS WR ƬYH \HDUV3

without nutritional compromise4

Aptamil Pepti GPS UIF FƉFDUJWF NBOBHFNFOU of cows’ milk allergy, without compromise 9 Unique blend GOS/FOS oligosaccharides to help reduce long-term allergy risk3 closer to 9 Extensively hydrolysed formula with a composition nutritionally 4 breastmilk, encouraging normal growth and development

9 Palatable for baby5, as convenient to prepare as standard infant formulas 'PS NPSF JOGPSNBUJPO PO UIF FƉFDUJWF NBOBHFNFOU PG $." WJTJU aptamilprofessional.co.uk References: 1. 7FSXJNQ ++ FU BM &VS + $MJO /VUS 4VQQM 4 4 2. (JBNQJFUSP 1( FU BM 1FEJBUS "MMFSHZ *NNVOPM 3. "STMBOPHMV 4 FU BM + #JPM 3FHVM )PNFPTU "HFOUT 4. 7BOEFOQMBT : FU BM + 1FEJBUS (BTUSPFOUFSPM /VUS 5. 7FOUFS $ $PXT NJML QSPUFJO BMMFSHZ BOE PUIFS GPPE IZQFSTFOTJUJWJUJFT JO JOGBOUT <0OMJOF> "WBJMBCMF BU IUUQT XXX KGID DP VL $PXT@NJML@QSPUFJO@BMMFSHZ@BOE@PUIFS@GPPE@IZQFSTFOTJUJWJUJFT@JO@ JOGBOUT@ BTQY <"DDFTTFE +BOVBSZ >

PAEDIATRIC

. . . the majority of children with suspected CMPA will be on a cows’ milk formula and require intervention using a hypoallergenic formula.

What is happening in practice?

Breast milk remains the best source of nutrition in children, also in those with CMPA and should be promoted as far as possible. A maternal elimination diet may be required, in particular in non-IgE mediated CMPA. Unfortunately, the UK has one of the worst breastfeeding rates in the world, which healthcare professionals need to be aware of and support practice as far as possible.21 This means that the majority of children with suspected CMPA will be on a cows’ milk formula and require intervention using a hypoallergenic formula. In 2010, Sladkevicius et al22 found that on average it took 2.2 months before infants with suspected CMPA were prescribed with the first clinical nutrition preparation and on average it took 3.6 months before the diagnosis of CMPA was made. Since that publication, abovementioned guidelines on how to diagnose and manage CMPA in the UK were published and there was an assumption that this would improve the identification and treatment of children with this allergy. However, a recent study by Lozinsky et al23 indicated that the average time for diagnosis continued to be around 2.2 months according to parents surveyed, and 48% of cases were diagnosed by the GP followed by 21% by paediatricians, 13% by the health visitor and in 5% by a dietitian.

Why has the diagnosis and initiation of suitable treatment for CMPA therefore not improved significantly since the publication of UK guidelines? Could it be that we do have a case of guideline overload, where healthcare professionals do not know which guidelines to follow, or are they confused with the content of guidelines? Many trusts have also developed their own guidelines for feed prescriptions based on local CMPA population and feed 20

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contracts. We do, therefore, have a situation where healthcare professionals are exposed to international, UK national and local guidelines, which understandably can be confusing.

In addition, there has been the belief in primary care, that CMPA is rare and that many primary care physicians would not deal with this diagnosis on a regular basis and, therefore, further education on this topic may have not received so much priority. However, in a study

by Lozinsky et al,23 in the 12-month period prior to completing the survey in primary care, 52% of the GPs diagnosed ≥3 children with CMPA and 65% managed ≥3 cases already diagnosed with this allergy. It is, therefore, an allergy that most healthcare professionals, even in primary care will be regularly exposed to.

Has the current financial climate contributed to a delay in commencing optimal dietary management? There has been more pressure placed on healthcare professionals to ensure cost savings and that includes evaluating the prescribing of hypoallergenic formulas. A recent review by the National Healthcare System (NHS) London Procurement Partnership indicated that the cost per annum on the NHS for the management of CMPA was 23.6 million.24 That survey found that the cost a year per patient on an EHF was £1,853 and AAF £3,161.25 Data has indicated that in Europe, the UK has the highest consumption on AAF; undoubtedly this does need review, but one has to take into account that the EuroPrevall study also indicated the highest prevalence of CMPA in the UK, which may also imply that we have a higher number of children with severe CMPA.26 Due to the cost implication of hypoallergenic formula, further guidelines were introduced in 2014 by the NHS PresQIPP,27 providing a traffic

light style guidance on first, second and third line feed choices based on specific commercial EHFs and AAFs, that take cost of hypoallergenic formulas into account. Using these guidelines, first line choice is always an EHF, which in theory should be suitable for the majority of children; however, second line choice is another EHF before an AAF is prescribed. Many children who would have had numerous feed changes prior to trialling hypoallergenic formulas will, therefore, potentially have further feed changes before symptom improvement may be achieved.

This does not only delay the diagnosis, but from the survey from Lozinsky et al,23 almost 47% of parents reported feelings of exhaustion, 55.7% had stress or anxiety related to their child’s health and 33% of fathers reported a delay in going back to work due to their child’s food allergy. Sladkevicius et al22 found that, in particular, frequent hypoallergenic feed changes have a health economic impact. Children from that study who remained on the same feed throughout their treatment had on average 1719 GP visits, whereas those who required feed changes needed >20 visits over the same period of time. Therefore, getting the management right from the start may consequently also relieve work pressures from already stretched primary healthcare practitioners.

The future

Prescott et al28 recently described the increase of food allergy as the second wave of the allergy epidemic, with the first wave occurring 50 years ago with asthma and allergic rhinitis. All healthcare professionals, therefore, will need to become more familiar with food allergic conditions. There is a general recognition that education on both recognition and management

of CMPA is key to improving the delay in initiation of suitable treatment.

A recent survey in dietetic competencies related to food allergy in the UK, Australia and North America, found that many dietitians did not feel competent in developing an elimination diet, food challenges and managing feeding difficulties.29 Reeves et al30 together with the Food Allergy Specialist Group of the British Dietetic Association, developed a one-day competencybased study day on CMPA. The results of that study day have indicated this as a useful format to improve both knowledge and competencies in CMPA. The course is currently run through the BDA in different areas of the UK (www. bda.uk.com/publications/events/160601cma) and has repeatedly yielded positive results.

However, it is important to note that the majority of children will first present to their general practitioner and/or health visitor. It is, therefore, crucial that education is focused on the healthcare professionals who will be the first port of call for parents. The challenge is to make the education easily accessible, time effective and practical within the current financial climate.

Conclusion

The diagnosis and management of CMPA remains a challenge. Several guidelines have been published to help healthcare professionals to not only identify symptoms, but also to guide maternal elimination diets and suitable hypoallergenic formulas for prescription. In addition to following these guidelines, it is important to ensure a patient-centred approach as this may not only improve the time to symptom resolution and, therefore, parent journey of CMPA, but may also reduce healthcare visits in an already stretched service. www.NHDmag.com April 2016 - Issue 113

21

PAEDIATRIC

Goat milk: an alternative infant feed Jacqui Lowdon Paediatric Dietitian - Team Leader Critical Care, Therapy & Dietetics, RMCH Presently team leader for Critical Care and Burns, Jacqui previously specialised in gastroenterology and cystic fibrosis.

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

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

Infant formulas made with cows’ milk have usually been the first choice when breastfeeding is not possible, or where there is insufficient breast milk. Now, the suitability and safety of goat milk as an alternative infant formula has recently been approved.

Until recently, the majority of conclusive studies in human infants published in the international literature have been limited to the evaluation of cows’ milk or soy protein-based infant formulae. Proteins from the milk of animals other than cows, or from various plant sources, have now been considered potentially suitable for use in infant formulae.5,6 The suitability and safety of goat milk, however, has only recently been approved.

Goat milk has a history of use for human nutrition in many cultures.7-9 Goat milk infant formulas have always been in demand, with reports of homemade goat formula and raw goat milk being used.10-13 The Dietetic Products, Nutrition and Allergies of European Food Safety Authority (EFSA) panel14 concluded that protein from goat milk is suitable as a protein source for infant and followon formulae. The final products must comply with the compositional criteria as per the EU Directive 2006/141/EC. This ruling occurred on March 2014 and goat milk infant formula is now available throughout the EU. Milk is produced in the mammary glands by forming minute droplets. These contain proteins, lactose, vitamins and minerals. Two different processes secrete these called merocrine and apocrine

secretion. In goat milk, the apocrine process has a greater role compared to that of cows’ milk.19 It is similar to human milk, as it contains numerous cytoplasmic particles that are broken off from the cell during apocrine secretion.15 It is during this secretory process that it is thought to naturally endow goat and human milk with the cellular components, free amino acids and nucleotides.

MEDIUM CHAIN FATTY ACIDS

Goat milk has a higher content of medium chain fatty acids (MCFA) compared to cows’ milk.16 Infant formula with goat milk fat contains 10-20% MCFA.17 This compares to human milk, which, depending on maternal diet, can contain up to 15% MCFA.18 COMPOSITIONAL PROPERTIES

Nucleotides Nucleotides are important constituents of RNA and DNA. During infancy, when rapid growth occurs, this can increase the need for nucleotides. It has already been well referenced that nucleotide supplementation increases weight gain and head growth in infants who are formula-fed. Therefore, in some formula-fed populations, nucleotides may be conditionally essential for optimal growth in infants.24

Table 1: Goat milk compared to cows’ milk Secreted by an apocrine process, similar to that of breast milk.19 Lower level of alpha s1-casein and greater proportion of beta-casein compared to cows’ milk and is more similar to human milk.20 More medium chain fatty acids than cows’ milk.22 Higher levels of bio active components such as nucleotides than cows’ milk, similar to human milk.23 Does not need to be whey-adjusted to be suitable for infant feeding. 20 www.NHDmag.com April 2016 - Issue 113

23

BREASTFEEDING IS BEST FOR BABIES

Why consider a goat whole milk formula?

Cow’s milk is commonly used to manufacture infant formula, generally because it is the most widely available source

NANNYcare is made from whole goat milk - now fully approved for use in infant formula

Approved since March 2014 Goat milk based formulas have been approved for use with infants since March 2014. The approval was based on a long-term growth study in infants with the NANNYcare formulation - Zhou et al (2014)1 .

Easy to digest The Goat milk itself has certain features which are more similar to human breast milk, such as forming a softer casein curd (than cow’s milk)2,3 which assists digestion. Because of these differences, casein-dominant (20:80) or goat ‘whole’ milk formula is equivalent to whey adjusted cow’s milk formula and is suitable for use from birth1.

A goat milk formula may simply suit some babies better 0800 328 5826 | enquiry@nannycare.co.uk | nannycare.co.uk IMPORTANT NOTICE: Breastfeeding is best for babies. Breast milk provides babies with the best source of nourishment. Infant formula milk and follow on milks are intended to be used when babies cannot be breast-fed. The decision to discontinue breast feeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breast feeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a babies health. Infant formula and follow up milks should be used only on the advice of a healthcare professional. Goat milk formula is not suitable for a cow milk protein allergy except under the supervision of a suitably qualified health care professional.

REFERENCES: 1. ZHOU et al (2014) Nutritional adequacy of goat milk infant formulas for term infants: a double blind randomised controlled trial. British Journal of Nutrition 111: No. 9 16411651. 2. STORRY, J.E., GRANDISON, A.S., MILLARD, D., OWENA, A.J. and FORD, G.D. (1983) “Chemical composition and coagulating properties of renneted milks from different breeds and species of ruminant”. Journal of Dairy Research 50(2): 215-229. 3. PARK Y. W., et al 2007. “Physio-chemical characteristics of goat and sheep milk”. Small Ruminant Research 68(1-2): 88-113.

Cow’s milk infant formulas are now routinely supplemented with nucleotides. However, goat milk formula already contains an array of nucleotides and so requires no supplementation.23 Protein and Amino Acids When expressed on a per-energy basis, goat milk infant formula has amino acids in amounts similar to human milk reference values.25 Historically, protein content of infant formula has always been set higher compared to human milk. The reasoning was due to concerns regarding the quality of the protein and insufficient amounts of some amino acids. However, there is now evidence that the protein content has been set too high. This can result in excess weight gain and place stress on a young infant’s immature kidneys.26,27 With this ‘growth acceleration hypothesis, suggesting that early and rapid growth during infancy programs the infant metabolic profile to be susceptible to obesity and the other components of metabolic syndrome, it is essential that infant formulas are brought in line with human milk reference values. It has also been demonstrated that in infants fed goat formula, blood urea levels are closer to those fed on human milk and, when compared to those fed cows’ milk formula, were actually 11% lower.20 This confirmed an adequate supply of amino acids from goat formula and less excess amino acids compared to a cow’s milk formula, with added whey proteins.

Whey proteins Whey proteins are often added to infant milk formulas to improve the quality of protein available as essential and semi-essential amino acids.28,29 However, goat milk infant formulas have been shown to have sufficient quantities of all essential and semi-essential amino acids, without the need to add whey proteins. They, therefore, have an amino acid profile compatible with international standards for infant formula.25 In an animal model, the amino acid digestibility and absorption properties of goat milk formula made with whole goat milk are similar to those of a cows’ milk infant formula with added whey.30 It has also been demonstrated that in goat milk formula made from whole goat milk, the amount and bioavailability of the amino acids provides less excess amino acids but still maintains

adequate growth of the infant.20 Therefore, there is no evidence supporting any advantage in adding extra whey proteins to goat milk infant formulas.

Adding whey also reduces the casein proteins in formula whilst increasing beta lactoglobulin.

This results in higher levels of proteins in whey enhanced formulas, which are not found in human milk.31 The lower levels of alpha s1 casein and the absence of added whey proteins in goat whole milk (80:20) formula means that the levels of nonhuman proteins are lower than when compared to either whey enhanced or casein dominated cows’ milk formula. These two proteins, alpha s1 casein and beta lactoglobulin, are known to induce allergic reactions in people sensitised to milk32 and so this maybe an important factor for goat milk formula.

NUTRITIONAL ADEQUACY

Infant formulas containing new sources of protein must be established for suitability and nutritional adequacy, as well as meeting international compositional standards.33,34 There has only been one previous randomised controlled trial using a goat milk infant formula fed to infants.35 It demonstrated that the growth of 30 infants fed a goat milk formula was similar to that of 32 infants fed a whey-based cows’ milk formula. However, the study was criticised for lack of blood biochemical data and numbers.36 Since then, a study has been published demonstrating that in infants, growth and nutritional outcomes provided by the goat milk formula did not differ from those provided by a standard whey-based cows’ milk formula. This study provided the evidence leading to the change that allowed goat milk as a base in infant formula.37 When comparing formula-fed infants with a breastfed group, Zhou et al37 also found some interesting differences in weight and weight for www.NHDmag.com April 2016 - Issue 113

25

CHARLIE’S BACK TO NORMAL. OH JOY. When a child is sick and malnourished, you just want to see them well again. PaediaSure’s full range of nutritional products supports them through the rough patch, and helps them get back to doing what kids do best.

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

THE PAEDIASURE RANGE. HELPING KIDS BE KIDS AGAIN.

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

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

Abbott Laboratories Ltd., 2013 (PaediaSure & PaediaSure Peptide vs. Peptamen Junior Powder). *Independent, head-to-head taste testing for PaediaSure, PaediaSure Plus, PaediaSure Fibre, PaediaSure Plus Fibre and PaediaSure Peptide vs. Fortini or Frebini Energy or Peptamen Junior Powder Date of preparation: July 2015 RXANI150119

PAEDIATRIC length z-scores. Their findings were consistent with other studies when comparing the growth of formula and breastfed infants.38-40 Whilst the differences in weight or weight for length z-scores continued at 12 months between the breastfed infants and cows’ milk formula-fed infants, there were no differences between the goat milk formula-fed infants and the breastfed infants. They used the same formula with a lower protein content for goat and cows’ milk formulas (2.0g/100kcals and 2.1g/100kcals for goat and cows’ milk formulas respectively) until 12 months, rather than changing to a follow-on formula at six months, which contains a higher protein content, as had been done in the other three studies. This might help to partly explain the difference observed between the findings of Zhou et al and the other three formula studies.

It had been demonstrated that weight for length z-score at 24 months in infants fed a low protein formula did not differ to that of breastfed infants.

However, infants fed a high protein formula (2.9g/100kcals) had higher z-scores.

An earlier study by Zhou et al20 measured how many times an infant was offered an alternative formula or non-formula foods before the age of four months, as a measure of compliance. In the group randomised to receive the cows’ milk formula, almost 40% of the infants were offered either another formula or a non-formula food for more than 12 days before the age of four months.

The rates in the infants fed the goat milk formula were far less and more similar to the breast milk fed infants.

When parents change their baby’s formula, or when complementary foods are introduced earlier than the recommendation, it is often said that it is done because the baby is not satisfied.

Although this needs to be investigated further, it could possibly suggest that they were more satisfied on the goat milk formula.

A more recent study48 has also compared the growth and nutritional status of infants fed goat milk-based formula (GMF) and cows’ milkbased formula (CMF). A total of 79 infants aged 0-3 months old were recruited and randomised in GMF or CMF group. The infants were fed the allocated formula to six months of age. GMFprovided growth and nutritional outcomes did not differ from those provided by CMF. 28

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INTESTINAL HEALTH

In the immature infant gut, development and maintenance of the protective gut barrier is important as allergic symptoms are often associated with increased intestinal permeability between the ages of six to 12 months of age.41 It has been demonstrated that goat milk prevents the loss of intestinal barrier function following heat stress in animals.42 This indicates the presence of factors helping to maintain intestinal health.

COWS’ MILK PROTEIN ALLERGY

It is estimated that 1.9% to 4.9% of children suffer from cows’ milk protein allergy43 Suggestions have previously been made that goat milk could be used as a possible nutritional alternative to cows’ milk for these infants. However, clinical studies have demonstrated a risk of crossreactivity between the proteins in cows’ milk and in goat milk.44,45 Infants with confirmed IgE-mediated cows’ milk allergy developing anaphylaxis after the ingestion of goat milk have also been reported.46 In 2012, EFSA concluded that ‘there is insufficient data on the allergenicity of goat milk protein, with no convincing data to support the conclusion that the incidence of allergic reactions is lower when feeding goat milk-based infant formula when compared with cows’ milk-based infant formula’.47 They also concluded that ‘substituting goat milk protein for cows’ milk protein in infant formula intended for cows’ milk allergic infants cannot be considered safe, unless proven to be so in clinical and in vitro studies’.

SUMMARY

There is now published evidence that goat milk infant formula is a safe and suitable alternative to cows’ milk and soy-based formulas. This has been confirmed by its approval for use. Goat milk has several properties that give it a greater similarity to human breast milk than cows’ milk. Also, there is no evidence to suggest that there is any advantage to including extra whey proteins in goat infant formula. Government advice at present is that ‘goat milk infant formula and follow-on formula is not suitable for infants with a cows’ milk protein allergy unless directed by a suitably qualified healthcare professional’.

IMD Watch

In association with the NSPKU

AN INTRODUCTION to GLYCOGEN STORAGE DISEASE type I Rychelle Winstone RD, BSc PGDipDiet Freelance Paediatric Dietitian Rychelle is a Paediatric Dietitian with a special interest in Inherited Metabolic Disease (IMD).

She has recently left the IMD team at the Evelina London Children’s Hospital and relocated to Pembrokeshire for her husband’s job.

Glycogen Storage Disease (GSD) is a term used to describe a diverse range of conditions involving defects in glycogen metabolism. Glycogen is a branched polysaccharide of glucose and acts as an energy store; mainly in the liver and skeletal muscle.

When the body is in a fasting or stressed state, glucagon and adrenaline stimulate glycogen breakdown (glycogenolysis) releasing glucose for use by the body.

Conversely, in a fed state, glucose is converted into glycogen and stored (glycogenesis).1 There are many types of GSD involving the liver, muscles and/or other organs. Some examples are listed in Table 1.2 Not all require a therapeutic diet. For the purposes of this article, we will refer to one type of hepatic GSD that requires intensive dietetic input: GSD Type I. In Figure 1 overleaf, you can see how the defective enzyme for this condition (glycogen-6 phosphatase) fits into overall hepatic glycogen metabolism.

Presentation

GSD Type I typically presents in the first year of life.3 It is rarely diagnosed in the neonatal period, as small infants feed frequently, but presents when periods of fasting are extended.2 The exact

prevalence is unknown, but is thought to be approximately one in 100,000 births.2 The stereotypical untreated child would present with a large round abdomen (caused by hepatomegaly), fasting hypoglycaemia, significant growth retardation and a ‘doll like’ face with chubby cheeks.2,3 However, there can be a vast degree of heterogeneity.

A specialist metabolic team can form a diagnosis by looking out for specific clues that differentiate between types; this would then be confirmed by genetic testing.

Hypoglycaemia is more prevalent in Type I than other types due to gluconeogenesis (making glucose from non-carbohydrate substrates such as pyruvate, lactate or gluconeogenic amino acids) being disrupted.3 Blood lactate levels are also high in GSD Type I: glucose-6-phosphate cannot form glucose, so is pushed down an alternate pathway to form lactate, while ketone body production is inhibited. This is

Table 1: Examples of Glycogen Storage Disease Types1,2 Type

Eponym

0 Ia

Enzyme deficiency Glycogen Synthase

Von Gierke

Ib

Glucose-6-phosphatase Glucose-6-phosphatase translocase

II

Pompe

Acid α-glucosidase

III a/b

Cori, Forbes

Debranching enzyme and subtypes

VI

Hers

Phosphorylase

IX XI

Phosphorylase kinase and subtypes Fanconi-Bickel

Glut 2 www.NHDmag.com April 2016 - Issue 113

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AD SPACE

Figure 1: Basic representation of Glycogen Metabolism

distinctly different from other types of GSD such as Type III, VI and IX - where high levels of ketones are produced.3 Life expectancy has improved considerably since initiation of treatment,4 which continues to evolve as global knowledge and experience widens. Long-term complications of GSD Type I can include hepatic adenomas/carcinomas, renal disease, osteopenia, ovarian cysts, anaemia and hypertension.4 In GSD Type Ib, there is additional neutropenia and impaired neutrophil function which can cause recurrent infections and inflammatory bowel disease (IBD).4 Principles of dietetic treatment

A multidisciplinary approach is vital, with specialist dietetic management at its core.

Treatment is individualised, but the overriding principals are to:2 • maintain normal blood glucose levels; • correct secondary biochemical abnormalities (not always possible);

• promote normal growth and maintain a healthy body mass index (BMI); • prevent long-term complications.

Because of the problems releasing a steady source of glucose, an exogenous source needs to be provided. This is initially based on normal basal glucose production rates (Table 2) and adjusted with regular monitoring. Some patients with milder forms of GSD may need only to eat regular meals and snacks and may be able to fast overnight, but with Type I, more intensive dietary input is required.2 Glucose requirements and fasting times tend to improve with age,2 but with infants and young children, fasting times can be as short as 90 minutes to two hours. Vitamin and mineral intakes need to be watched closely and supplemented accordingly, as prescribed carbohydrate can displace nutrient rich foods.2 Dietetic treatment for GSD Type I varies around the world. A prime example of this is the restriction of fructose and galactose in parts of Europe and the US. This is based on the www.NHDmag.com April 2016 - Issue 113

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IMD watch Table 2: Glucose requirements used in GSD5 Glucose (g/kg/h)

Age

Day

Infants Toddlers & children Adolescents & adults

premise that they increase lactate production via glycolysis.2 In the UK, we do not restrict as it is felt that slightly elevated lactate levels can be a protective element during hypoglycaemia, providing an alternative fuel for the brain.2 Overnight feeding

In the 1970s, continuous overnight enteral feeding was introduced to GSD treatment.6 This enables a steady, controlled source of glucose to be provided overnight without waking an infant or child frequently for feeding. Managing without an overnight feed can be disruptive or unachievable, especially with very short fasting times.

In infancy, the overnight feed consists of infant formula and is transitioned towards a glucose polymer feed with added micronutrients as the child gets older.2 A bolus of overnight feed must be given immediately before the feed is started and upon stopping (half the continuous rate), ensuring that the child is covered for the first part of the feed, and for 30 minutes once the feed is stopped.2 With the benefits of overnight feeding also come risks. A nasogastric (NG) tube needs to be used until hepatomegaly sufficiently resolves and it is safe to insert a gastrostomy. In GSD Type Ib, NG feeding is needed long term as a gastrostomy poses an infection risk.2 Community health professionals must be made aware of this as overnight NG feeding is usually not permitted due to risk of tube displacement/aspiration. Even with a gastrostomy, the risk of feed discontinuation can pose the threat of hypoglycaemia.2 Families are trained to use the feeding equipment and make up feeds correctly. Bed wetting alarms are given to help identify leakages during the night. Some families choose not to have an overnight feed, preferring frequent feeding or UCCS doses.

Corn starch

The 1980s saw the introduction of uncooked corn starch (UCCS).7 This slowly releases 32

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Night

0.5

0.5

0.3-0.4

0.3-0.4 0.2-0.25

glucose to help maintain normal levels and lessens the need for very frequent feeding.2 It is usually introduced in children aged one to two years and above, as it is thought that before this age it is not effectively utilised by the body.2,3 The starting dose is usually 1.0-2.0g/kg,2 once per day and must be built up slowly at home to prevent gastrointestinal side effects. UCCS must be given cold or at room temperature, mixed into a drink such as water, milk or squash, or mixed into yoghurt or custard. In cases where the child refuses the UCCS, it can be administered via feeding tube, but care needs to be taken not to cause blockages.

A modified starch (Glycosade) is used with some GSD patients. More research is needed and is planned in the UK; initial studies have shown that Glycosade may be able to achieve a longer duration of normoglycaemia than UCCS, smoother blood glucose response and improved metabolic control.8,9,10 Carbohydrate portioning

While enough carbohydrate needs to be provided to prevent hypoglycaemia and metabolic derangements, providing too much can also result in adverse effects. Excess adiposity and glycogen storage, along with hyperlipidaemia and swings in blood glucose levels can all arise from giving too much carbohydrate.4 In some GSD patients, carbohydrate counting can be a very useful tool to ensure that the right amount of carbohydrate is given at meals and snacks. In some children who are not carbohydrate counting, advice surrounding carbohydrate portion sizes is given, taking into consideration prescribed carbohydrate from UCCS and/or the overnight feed. Carbohydrate from complex, starchy foods rather than sweet sugary ones is advised and healthy eating advice is a priority.

Glycogen storage disease in liver

Image: Nephron

Management of illness

In times of illness, it is important to ensure a supply of glucose to prevent hypoglycaemia and metabolic instability, at least the glucose requirements for age.3 Families are taught an emergency regimen which consists of a glucose polymer solution given at regular intervals (usually two-hourly or continuously via a feeding pump), providing sufficient carbohydrate and fluid.2 If this is not tolerated, hospital admission is necessary to commence IV dextrose.3 Monitoring

Children with GSD Type I need close monitoring. Growth is particularly important, as it is a key indicator that the prescribed treatment is effective.2 Changes to feeding regimens need to be made regularly as children grow. A specialist metabolic team is likely to regularly admit children for ‘profiling’. This involves the child being fed their usual diet, and measurements (glucose + lactate for GSD Type I) being taken before each meal, snack, UCCS dose and before, after and during the overnight feed if they have one. Continuous

Glucose Monitoring (CGM) may also be used in the home environment.

Challenges

GSD can be a challenging and distressing disorder to manage for families, particularly in children prone to hypoglycaemia. Frequent feeding needs to be regimented, and sometimes missing a feed by a matter of minutes can cause a child to become hypoglycaemic. The multidisciplinary team needs to provide sufficient education and support to ensure that families have the tools to manage.

Picky eating is also common; this is compounded by frequent feeding and can be extremely stressful for families, especially when regular feeds are the basis of treatment. A ‘backup’ feed may be necessary to administer via a feeding tube to prevent any food aversions worsening.

Conclusion

GSD Type I requires intensive dietary treatment and care from a specialist, multidisciplinary metabolic team. Treatment and knowledge is continuously evolving, and hopefully long-term outcomes will continue to improve.

References 1 Mundy H, Lee P (2004). The glycogen storage diseases. Current Paediatrics; 14: 407-413 2 Dixon M (2015). Disorders of Carbohydrate Metabolism: Glycogen Storage Disorders. In: Shaw V (Ed). Clinical Paediatric Dietetics (4th edition). Wiley Blackwell Publishing, pp541-560 3 Laforêt P, Weinstein D.A, Smit PA (2012). The Glycogen Storage Disease and Related Disorders. In: Saudubray J-M, van den Berghe G, Walter J (Eds.). Inborn Metabolic Diseases: Diagnosis and Treatment (5th edition). Berlin Heidelberg: Springer, pp116-123 4 Rake JP, Visser G, Labrune P et al. Guidelines for management of Glycogen Storage Disease Type I. European Study on Glycogen Storage Disease Type I (ESGSD I) (2002). Eur J Pediatr; 161: s112-s119 5 Bier D, Leake R.D, Haymond MW et al (1977). Measurement of true glucose production rates in infancy and childhood with 6,6-diodeuteroglucose.

Diabetes; 26(11): 1016-23 6 Burr IM, O’Neill JA, Karzon DT et al (1974). Comparison of the effects of total parenteral nutrition, continuous intragastric feeding, and portacaval shunt on a patient with Type I Glycogen Storage Disease. J Pediatr; 85: 792-795 7 Chen YT, Cornblath M, Sidbury JB (1984). Corn starch therapy in Type I Glycogen Storage Disease. N Engl J Med; 310: 171-175 8 Correia CE, Bhattacharya K, Lee PJ et al (2008). Use of modified corn starch therapy to extend fasting in Glycogen Storage Disease Type Ia and Ib. Am J Clin Nutr; 88: 1272-1276 9 Bhattacharya K, Orton RC, Qi E et al (2007). A novel starch for the treatment of Glycogen Storage Diseases. J Inherit Metab Dis; 30: 350-357 10 Corrado MM, Ross KM, Brown LM et al (2013). Assessment of safety and efficacy of extended release corn starch therapy in Glycogen Storage Disease. J Inherit Metab Dis; 36: P437

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case study: ULCERATIVE COLITIS (IBD) The impact of IBD on the nutritional status and life of an 18 year old Emma Coates NHD Editor

Part 1: Symptoms, diagnosis and early management Please note that Part 2 of this article can be viewed in the Subscriber Zone online only at www.NHDmag.com

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.

Please note that Part 2 of this article can be viewed at NHDmag.com

Case Study Somewhere in the distance a radio is playing, the DJ chirps about the latest pop hit and happily wishes everyone a good morning. It’s 8.25am and 18-year-old Maria is looking down at her bare legs and feet, dangling over the edge of a hospital trolley, feeling a little woozy from the premed. Wearing a hospital gown, she feels a slight chill as the anaesthetist is behind her, pressing an epidural needle into her spine. “There we go, all done. You can lay back down now,” he says. Along comes the nurse; she clanks the brake off the trolley with her foot and it starts to move forward. Maria looks up at the white polystyrene tiled ceiling, dotted with bright strip lights, passing overhead like neon clouds; she’s calmly wheeled down the corridor to the theatre area where she will undergo major bowel surgery. It has been quite a journey to get here…

At the age of 16, Maria was diagnosed with Ulcerative Colitis (UC) following several weeks of abdominal pain and diarrhoea (Please see Table 1 for a brief outline of UC). Throughout her earlier teenage years, Maria had been an active girl with a good appetite. There was no family history of bowel problems, such as coeliac disease, IBS or inflammatory bowel disease (IBD). At her first GP appointment, following two weeks of abdominal cramps and some diarrhoea, he initially concluded that Maria had had a ‘stomach bug’ and asked her to return if her symptoms did not improve. Two weeks later, when her symptoms had not improved but had worsened, she returned to her GP who requested blood tests and a stool sample. (Please see Table 2 for common tests for IBD.) Maria had been experiencing daily abdominal pain, frequently bloody diarrhoea. She was also complaining of fatigue and feeling generally unwell.

Her blood tests showed that her FBC and serum ferritin level were low, but not out of range; she was displaying signs of inflammation with raised CRP, ESR and WBC. She was negative for coeliac disease. Her stool sample was negative for bacterial or parasitic infections; however, it was noted that there were traces of blood within the sample. She had also been experiencing loss of appetite and her GP was concerned that she had lost approximately 3.0kg in four to five weeks.

Maria explained that this (approximate) 5% weight loss was unintentional. It was due to her feeling nauseous at times and she was now quite anxious about eating; afraid it would cause her increased abdominal discomfort and diarrhoea.

Her usual BMI was 20.9km/m2 (height 1.65cm, weight 57kg). On presentation to this second GP appointment, her weight was 54kg (BMI 19.8km/m2).

When Maria and her GP discussed her dietary intake, it was apparent that it had reduced by as much as 50% due to her gastrointestinal (GI) symptoms.

She was avoiding some foods, such as fresh vegetables and fruits, milk, high fibre cereal and bread. She felt that these foods increased stool frequency and

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CONDITIONS & disorders

She was also afraid to go along to social events with her peers due to her need to be close to a toilet, and the anxiety she had about discussing her condition. She had similar worries at work. abdominal discomfort. Her GP advised lower fibre foods to tolerance, e.g. white bread and pasta with high calorie, protein-containing foods such as cheese, white meat or fish. He also advised her to fortify her food with extra butter, for example, with mashed potatoes or on cooked vegetables, which she was managing at that time. A little and often approach with food was agreed as the best way forward, where high calorie small meals, snacks and drinks would be taken every two to three hours. In light of her test results, Maria was referred to her local hospital’s gastroenterology team.

This team reviewed her approximately six weeks afterwards. Her weight was monitored again at this time and she had experienced a further 5% weight loss (BMI 18.7km/m2 (height 1.65cm, weight 51kg). Prior to this initial appointment, she underwent a repeat set of blood tests, which showed continued raised inflammatory markers and her serum ferritin level, along with her FBC, had worsened. She was diagnosed with iron deficiency anaemia.

Maria attended the hospital two weeks later for a colonoscopy, the outcome of which was a firm diagnosis of UC. Her gastroenterology consultant gave her this diagnosis at a follow-up outpatient appointment approximately four weeks later. He explained that UC was a chronic and ongoing condition with a variety of treatment options. (Please see Table 3 for common treatments used in UC.) By this time, Maria had lost another 2.0kg and her BMI was now 18km/m2 (height 1.65cm, weight 49kg). She felt tearful and embarrassed that she was experiencing significant urgency to pass very loose stools up to 15 times per day. This had started to occur at night time too, which she felt was affecting her energy levels during the day. She was experiencing broken sleep most nights. Consequently, she had been missing several days per week of her college course due to her lack of energy and GI symptoms. This created further anxiety for Maria as she was falling behind with her academic work. She was also afraid to go along to social events with her peers due to her need to be close to a toilet, and the anxiety she had about discussing her condition. She had similar worries at work. Maria worked part time in a supermarket and she struggled to speak to her colleagues and manager about her health problems.

Her dietary intake diminished further despite her efforts to eat little and often. She was tolerating only plain bland foods, such as mashed potato with tinned tuna, porridge with semi-skimmed milk and sugar, ready salted potato crisps and ham sandwiches made with white bread. She was managing small portions of these foods and she described her appetite as 25% of what it would normally be. She was drinking good amounts of fluids via 800ml of diluted full sugar squash, up to two ‘cup-a-soup’ type drinks (made up to 250ml each) and two to three cups of tea with milk (made up to 250ml each) per day. She continued to avoid milk as a drink, as she felt it increased her abdominal discomfort and the thought of drinking milky drinks made her feel nauseous. Maria was commenced on an anti-inflammatory medication, Mesalazine, antidiarrhoeals, Loperamide and a course of iron replacement therapy. She was not referred for nutritional advice at this time and the gastroenterology team planned to review her in three months.

At her next review, Maria’s weight had remained static at 49kg. She was feeling better in herself and her GI symptoms had eased. She was still experiencing loose stools with urgency up to eight times per day. However, this had decreased significantly at night. Her appetite and dietary intake 36

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Table 1: Overview of ulcerative colitis (adapted from www.crohnsandcolitis.co.uk)1,2 Ulcerative Colitis (UC) is one of the two main Inflammatory Bowel Diseases.

Approximately one in 420 people (around 146,000 people) in the UK have UC. It’s a chronic long-term condition.

The inner lining of the large intestine and rectum become ulcerated and inflamed causing bleeding and mucus to be secreted.

Inflammation can affect all of the large intestine, known as Pancolitis or Full colitis. It can also affect the rectum only, known as Proctitis.

Affects male and females equally.

Most commonly diagnosed between 15-25 years of age.

Common in white people of European decent.

More common in urban areas and in Northern developed countries.

More common in non-smokers and ex-smokers.

Symptoms Diarrhoea/Bloody stools Abdominal pain/discomfort, cramping Fatigue, sometimes severe Feeling generally unwell, sometimes feverish Poor appetite and/or weight loss Anaemia Joint, liver, eye and skin conditions can develop as a consequence of UC Extensive or total colitis (Pancolitis) over many years is associated with an increased risk of rectal or colon cancer

had improved a little, but she was still maintaining a plain bland diet which was similar to that previously reported. As her status was stable, the gastroenterology team planned a further review in three months’ time. However, four weeks after her review Maria became unwell with a cold, she felt generally unwell and her appetite reduced. Despite her dietary intake being minimal for several days, she was experiencing loose, bloody stools with urgency almost every hour. She was breathless on exertion, where even having a shower was exhausting. When offered food and drink, she became nauseous and would vomit if she tried to consume them, even water. She was admitted to hospital due to dehydration and severe abdominal pain.

On admission, she was weighed and she had lost 3.0kg. Her BMI was 16.9kg/m2 (height 1.65cm and weight 46kg). After three days as an inpatient, Maria’s GI symptoms improved and she was eating and drinking small amounts. She was discharged on a course of steroids and immunosuppressant medication, Azathioprine. Over the next month, Maria’s symptoms improved greatly, she gained 4.0kg and reported that she was eating really well. She had started to eat a wider variety of foods, including lasagna, roast chicken dinners with vegetables and she had reintroduced some fresh fruits, such as banana, melon and satsumas.

At her next review appointment, which was four weeks after her admission, the gastroenterology team advised her to continue with the steroid treatment and Azathioprine for another six weeks, after which the steroid treatment would be gradually reduced, as this was not a long-term option.

Maria followed this advice and felt well for the first few reductions in the steroid treatment.

However, once the treatment had reached approximately half its full strength, her GI symptoms returned. She was experiencing loose, urgent stools and abdominal discomfort. For the following 18 months, Maria experienced a revolving door of being well, then experiencing severe GI symptoms every few months. Her weight fluctuated between 49-54kg, as she was prescribed several courses

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CONDITIONS & disorders of steroid treatment alongside the Azathioprine. This cycle of remission then ‘flare up’ meant that Maria missed too much of her college course to complete her examinations and she decided to discontinue her studies. At a similar time, she gave up her part-time job, as she felt too weak to continue.

This had a huge psychological impact on Maria; she felt low in mood and her confidence dwindled.

She was angry to have lost control of her health and her life to UC. She was often tearful and dreaded waking up in the morning, as she knew she would feel fatigued and frustrated. Eating and drinking became ‘autopilot’ functions, where she would eat the same foods most days, as it was easy to cope with. She did not want to eat anything else, food held little enjoyment for Maria at that time.

Just after her 18th birthday, Maria attended her usual three-to-four-monthly gastroenterology review.

She was feeling unwell, she was experiencing a ‘flare up’, where she had a constant dull ache in her abdomen, she was passing loose bloody stools every hour and she was tolerating only small amounts of a plain bland diet. According to the Truelove and Witts’ severity index, she was experiencing severe UC.5 Tired of being unwell and fatigued, Maria became very emotional during her discussions with the gastroenterology consultant. It was at this time that he raised the option of surgical intervention.

This was a challenge for Maria to accept, as continuing with her current treatment was unlikely to be a successful path, yet surgical intervention was terrifying. What was worse? Continuing with her current situation or having surgery to remove her large intestine and fashion a new pouch from her small intestine: a restorative proctocolectomy with ileoanal pouch (see Table 3)? It was a major decision to make at the age of 18, but Maria felt that she had no choice. Surgery was the best option and two months later, she was booked in for the procedure. Weighing 45kg (BMI 16.3kg/m2), Maria was malnourished, but she was not referred for dietetic intervention at this time.

Keep reading! Part 2 of this case study is available online in the Subscriber Zone at www.nhdmag.com and includes Maria’s post-surgical experiences, diet with an ileostomy and, finally, her ileoanal pouch.

Table 2: Common bloods tests used in Inflammatory Bowel Disease (adapted from www.labtestsonline.org.uk)3 Blood tests White blood cell count as part of a full blood count (anaemia screening included) ESR (erythrocyte sedimentation rate) CRP (C-reactive protein) Coeliac disease screening Stool tests: Stools sample examinations to exclude other causes of diarrhoea and inflammation Stool culture

To detect bacterial infection.

Ova and parasite examination

May cause diarrhoea and temporary bowel inflammation.

Clostridium difficile screening

To detect toxin created by bacterial infection, which may follow antibiotic therapy.

White blood cell count (WBC)

To detect the presence of WBC, indicative of infection or inflammation.

Faecal calprotectin

A protein found in cells associated with inflammation. The concentration of calprotectin in faeces correlates with the level of bowel inflammation present. The concentration of faecal calprotectin therefore tends to be increased in IBD (a disease characterised by inflammation), but not in IBS (Irritable bowel syndrome, a disease which is not characterised by inflammation). A negative faecal calprotectin result supports the diagnosis of IBS. National Institute for Health and Care Excellence (NICE)4 recommend that faecal calprotectin testing might be useful to support clinicians in differentiating IBD from IBS. Monitoring calprotectin may also be useful to help monitor IBD and detect a flare-up.

38

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Table 2 continued Non-laboratory tests – for diagnosing and monitoring IBD. Used to look for characteristic changes in the structure and tissues of the GI tract Barium meal and follow through

Barium contrast dye is ingested by the patient followed by abdominal x-rays to examine the small intestine.

Sigmoidoscopy

An examination the last two feet of the colon using an endoscopy. Biopsies may be taken.

Colonoscopy

An examination of the entire colon; using an endoscopy. Biopsies may be taken.

Biopsy

Small tissue samples taken from the large intestine to be examined for inflammation and abnormal cell structure changes.

MRI and CT scans.2,9

May be used to look at the location and extent of inflammation Ultrasound may be used in some cases, e.g. pregnancy and IBD.

Table 3: Treatment options in UC (adapted from Crohn’s and Colitis UK - Ulcerative Colitis: Your guide2) Anti-inflammatory drugs - to reduce inflammation Aminosalicylates or 5-ASAs

Mesalazine (brand names include Asacol, Ipocol, Octasa, Pentasa, and Salofalk), sulphasalazine (Salazopyrin), olsalazine (Dipentum), balsalazide (Colazide)

Corticosteroids, often just called steroids

Prednisolone, hydrocortisone, budesonide, beclometasone dipropionate

Immunosuppressants

Azathioprine, mercaptopurine or 6MP (Purinethol), methotrexate, mycophenolate mofetil, tacrolimus and ciclosporin

Biological drugs

Infliximab and vedolizumab

Symptomatic drugs - to control and reduce common GI symptoms Antidiarrhoeals

Codeine phosphate, diphenoxylate (Lomotil) and Loperamide (Imodium, Arret)

Laxatives

Movicol and Lactulose

Bulking agents

Fybogel

Analgesics

Paracetamol and aspirin

Probiotic therapy VSL#3

A probiotic containing eight different strains of bacterial (450 billion per sachet).6 There is evidence to suggest it may be helpful in preventing pouchitis7,9 (inflammation of an ileo-anal pouch - further information below). However, there is limited evidence for the use of probiotics in maintaining remission in people with UC.8,9

Surgical options Proctocolectomy with permanent ileostomy

Removal of the whole large intestine, rectum and anal canal. The end of the lower small intestine is brought onto the wall of the abdomen to form a permanent ileostomy. This form of surgery is irreversible.

Restorative proctocolectomy with ileoanal pouch

Often called pouch surgery, or IPAA (Ileal Pouch-Anal Anastomosis). The preferred form of surgery for UC. Requires two operations, but may be completed in a single stage or in three stages.

In the first operation the whole large intestine and the rectum are removed, the anus is left in situ. A pouch is constructed using the end of the ileum, which is joined to the anus. A temporary ileostomy is formed by bringing a looped section of the small intestine onto the wall of the abdomen. This allows the newly formed pouch anastomosis to heal. This takes several months.

To close the temporary ileostomy a second operation will take place once the pouch is healed. In very rare cases, the whole procedure is done in one stage, without the ileostomy. www.NHDmag.com April 2016 - Issue 113

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CONDITIONS & disorders Table 3 continued Colectomy with ileorectal anastomosis

Removal of the whole large intestine. The ileum is joined to the rectum. It avoids the need for a stoma.

Can be useful for people who may not cope with an ileostomy or who are unsuitable for pouch surgery.

This operation is only suitable if there is little or no inflammation in the rectum or if there is no long-term risk of developing cancer in the rectum.

Colectomy with ileostomy (subtotal)

Often performed in an emergency. Removal of the whole large intestine but leaves the rectum in situ. This allows for the possibility of pouch surgery in the future. The end of the ileum is brought out onto the abdomen wall to form an ileostomy.

The upper end of the rectum is either closed or brought out to the surface to form another stoma.

This additional stoma (sometimes called a mucous fistula) may be needed because the rectum may still produce mucus for a while. After recovering from this surgery, patents can then decide whether to opt for pouch surgery or a permanent ileostomy.

References 1 Crohn’s and Colitis UK (2013) - www.crohnsandcolitis.org.uk/about-inflammatory-bowel-disease/ulcerative-colitis <accessed 03/03/16> 2 Crohn’s and Colitis UK (2016) - http://s3-eu-west-1.amazonaws.com/files.crohnsandcolitis.org.uk/Publications/ulcerative-colitis.pdf <accessed 03/03/16> 3 Lab tests online UK - http://labtestsonline.org.uk/understanding/conditions/inflammatory-bowel/start/1 <accessed 03/03/16> 4 National Institute for Clinical Excellence (2013). Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel. NICE diagnostics guidance (DG11) Available at www.nice.org.uk/guidance/dg11 <accessed 03/03/16> 5 National Institute for Clinical Excellence (2013). Ulcerative colitis: management. NICE guidelines (CG166) Available at www.nice.org.uk/guidance/cg166/ chapter/1-recommendations#severity-of-ulcerative-colitis <accessed 03/03/16> 6 About VSL#3 - www.vsl3.co.uk/all_about_vsl3.php <accessed 03/03/16> 7 Paolo Gionchetti, A Andrea Calafiore, A Donatella Riso, A Giuseppina Liguori, A Carlo Calabrese, A Giulia Vitali, B Silvio Laureti, B Gilberto Poggioli, B Massimo Campieri, A and Fernando Rizzelloa (2012). The role of antibiotics and probiotics in pouchitis. Ann Gastroenterol. 25(2): 100-105.

8 Naidoo K1, Gordon M, Fagbemi AO, Thomas AG, Akobeng AK (2011). Probiotics for maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev. 2011 Dec 7; (12): CD007443. doi: 10.1002/14651858.CD007443.pub2 9 Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, Driscoll R, Mitton S, Orchard T, Rutter M, Younge L, Lees C, Ho G, Satsangi J, Bloom S. On behalf of the IBD Section of the British Society of Gastroenterology (2011). Guidelines for the management of inflammatory bowel disease in adults. Available at www.bsg.org.uk/images/stories/docs/clinical/guidelines/ibd/ibd_2011.pdf <accessed 03/03/16>

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food and drink

ANCIENT GRAINS in the modern diet Gemma Sampson Rd, Senior R&D Dietitian, Vitaflo International

In our modern-day health-conscious society, ancient grains are back in vogue and appearing more frequently in ingredient lists of foods on our supermarket shelves. Traditionally, eight grains are considered cereals: wheat, rice, corn, oats, rye, barley, millet and sorghum.

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.

Of these grains, wheat, corn and rice make up the bulk of the world’s grain production and consumption. With the ever-increasing popularity of the paleo diet and ‘clean eating’, many people are turning away from these modern staple crops and choosing alternative ancient grains.

‘Ancient grains’ is one of the latest health marketing buzzwords. Similar to superfoods, there is no real definition of what classifies an ancient grain.

For the health-conscious consumer, foods containing ancient grains can evoke perceptions of a food being more wholesome, nutritious and less processed. They are now becoming more commonplace in everyday foods from breads, cereals and even drinks.

Ancient grains are being marketed as nutritional powerhouses that are ‘cleaner’ choices than the standard wheat or rice varieties. They reportedly haven’t been selectively bred to the same extent as their modern staple crops and claim to be nutritionally similar to those strains enjoyed by Incan, Aztec and other ancient civilisations.

Ancient grains include both grains (seeds of grass plants) and pseudo-grains (seeds of non-grass plants) that have reportedly remained unchanged in their nutritional status for millennia. As seeds of non-grass plants, buckwheat, amaranth and quinoa aren’t classified as true grains.

However, since they are typically grown and cooked in a similar manner to more traditional grains, they are considered to be pseudograins.

THE ANCIENT GRAIN HEALTH-HALO

Market research shows that consumption of ancient grains is on the rise and consumers are willing to pay a premium price. This indicates that ancient grains are a health-halo worth being shopping savvy about. While in their wholegrain form, ancient grains can be nutritionally superior to modern staple grains, when used as refined flours or in tiny amounts as an ingredient, the nutritional difference may be negligible. Many new foods boast to contain ancient grains, riding on the health-halo effect, convincing consumers to purchase products that may be nutritionally similar, if not inferior, to the standard version. Some of these products contain a little as 1% of the claimed ancient grain in the ingredients list, making their nutritional contribution minimal.

A perfect example of the health-halo effect is a version of Cheerios in the US containing the ancient grains quinoa, spelt and kamut wheat. Consumers may purchase the product on the assumption that the inclusion of these ancient grains means it is a more wholesome choice than the original. However, upon looking at its nutritional profile, the ‘lightly sweetened’ ancient grains variety contains five times more sugar than the original, making it a less nutritious choice.

NUTRITIONAL BENEFITS OF ANCIENT GRAINS

When consumed in their wholegrain format, ancient grains are typically higher in protein and fibre, providing more vitamins, minerals and other www.NHDmag.com April 2016 - Issue 113

41

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Table 1: Nutrition composition per 100g uncooked grain Wheat

Brown AmarRice anth

Buckwheat groats

Chia

Kamut Quinoa

Millet

Sorghum

Spelt

Teff

Energy (kJ/ kcal)

342

362

371

343

486

337

368

378

329

14.6

367

Fat

1.7

2.7

7.0

3.4

30.7

2.1

6.1

4.2

3.5

2.4

2.4

Saturated

0.3

0.5

1.5

0.7

3.3

0.2

0.7

0.7

0.6

0.4

0.4

Monounsaturated

0.2

1.0

1.7

1.0

2.3

0.2

1.6

0.8

1.1

0.4

0.6

Polyunsaturated

0.8

1.0

2.8

1.0

23.7

0.6

3.3

2.1

1.6

1.3

1.1

Carbohydrate

75.9

76.2

65.3

71.5

42.1

70.6

64.2

72.9

72.1

70.2

73.1

Sugar

0.4

1.7

-

-

7.8

-

2.5

6.8

1.8

Protein

11.3

7.5

13.6

13.3

16.5

14.5

14.1

11.0

10.6

14.6

13.3

Fibre

12.2

3.4

6.7

10.0

34.4

11.1

7

8.5

6.7

10.7

8.0

Calcium

32

33

159

18

631

22

47

8

13

27

180

Iron

4.6

1.8

7.6

2.2

7.7

3.8

4.6

3.0

3.4

4.4

7.6

Magnesium

93

143

248

231

335

130

197

114

165

136

184

Phosphorus

355

264

557

347

860

364

457

285

289

401

429

Potassium

432

268

508

460

407

403

563

195

363

388

427

Sodium

2

4

4

1

16

5

5

5

2

8

12

Zinc

3.3

2.0

2.9

2.4

4.6

3.7

3.1

1.7

1.7

3.3

3.6

thiamin

0.4

0.4

0.1

0.1

0.6

0.6

0.4

0.4

0.3

0.4

4

Riboflavin

0.1

0.04

0.2

0.4

0.2

0.2

0.3

0.3

0.1

0.1

0.3

Niacin

4.4

4.3

0.9

7.0

8.8

6.4

1.5

4.7

3.7

6.8

3.4

Vitamin B6

0.4

0.5

0.6

0.2

-

0.3

0.4

0.4

0.4

0.2

0.5

Vitamin E

1.0

-

1.2

-

0.5

0.6

2.4

0.05

0.5

0.8

0.1

*Nutrient data obtained from the USDA nutrient database

nutrients than their modern counterparts. This can make them superior choices - particularly for those on a gluten-free diet. However, these claims are not hard and fast statements, as nutritional quality will differ according to the variety, soil and conditions under which the grains are grown.

Table 1 compares the nutritional composition of a number of ancient grains in their raw, uncooked format to both whole, wheat and brown rice.

Nutritional composition of ancient grains is also influenced by cooking methods and whether they have been refined from their wholegrain form.

Sorghum, millet, teff, amaranth, buckwheat and quinoa are ancient grains that are naturally

gluten-free and suitable for individuals with coeliac disease or gluten intolerances. However, einkorn, emmer (farro), freekeh, kamut and spelt are all heirloom varieties of wheat containing gluten and are unsuitable choices. They are often marketed as being lower in gluten, with claims that they are better tolerated and digested due to having not been selectively bred to the same extent.

Amaranth Amaranth is a small gluten-free pseudo-grain originating from South America with a light and mild nutty flavour. Nutritionally it is high in protein, vitamin C, iron and calcium. When www.NHDmag.com April 2016 - Issue 113

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PUBLIC HEALTH

Amaranth is a small gluten-free pseudo-grain originating from South America with a light and mild nutty flavour.

Nutritionally it is high in protein, vitamin C, iron and calcium.

are often used to make chia puddings with dairy or dairy-free milks, sprinkled onto smoothies or cereal or mixed into baked goods.

Image: Tubifex Wikimedia Commons

cooked it can be used as a gluten-free alternative to couscous, or can be ground into flour and used in baking.

Buckwheat Buckwheat is a pseudo-grain, a seed fruit related to rhubarb that originated in northern Europe and Asia. High in fibre and protein, it is a glutenfree grain, despite the word ‘wheat’ in its name.

Buckwheat groats contain the best nutrient profile as an intact, wholegrain which can be toasted to reduce cooking time and develop a pleasant nutty flavour. Buckwheat used instead of barley in soups, as a porridge, or ground into flour to make gluten-free pancakes, cakes and other baked goods. Toasted buckwheat groats take about 15-20 minutes to cook, while the untoasted grain takes 20-30 minutes.

Chia seeds Technically, neither a grain nor a pseudograin, chia, however, is frequently included under the ancient grain banner in food products.

Rich sources of protein, fibre and heart healthy polyunsaturated fats, chia seeds are packed full of other nutrients including calcium, iron and zinc. They absorb liquid to form a viscous gel and 44

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Farro, Emmer and Einkorn Farro is the Italian name for three varieties of heirloom grains: emmer einkorn and spelt. It is a low-yielding member of the wheat family that can grow in arid conditions. Originating in Egypt, it has been found in the tombs of ancient Egyptian kings, was allegedly carried by ancient Roman legions in their rations for its nutritional composition and consumed frequently in Italy.

Farro has a nutty flavour, chewy texture and is high in fibre, protein, zinc, magnesium and iron.

Wholegrain farro requires overnight soaking to avoid tough kernels and cooking times of well over an hour. Pearled and semipearled farro has had some of the bran removed and can be cooked without soaking in a similar manner to rice within 15-25 minutes. Farro can be added into soup, served al dente in salads and can used to make pasta or bread.

Freekeh Freekeh is a young, roasted green wheat with a unique smoky aroma and nutty toasted taste.

Native to Lebanon, Jordan, Syria and Egypt, freekeh is harvested young (green) when the grains are still soft, dried, roasted to burn off the chaff and develop a golden colour then polished and cracked. Freekeh is high in protein, fibre, iron, magnesium and zinc. It is low in GI and has a low insulin response which may make it helpful for people with Type 2 diabetes. Freekeh can be used as an alternative to couscous or rice, added to soups, used in salads or cooked into a porridge.

Kamut® khorasan wheat Kamut is a trademarked brand of wheat that is reported to be a modern descendent of an ancient Egyptian grain. It is high in protein and contains plenty of B vitamins, phosphorus, zinc and magnesium.

Kamut is a large, sweet, nutty flavoured grain that is significantly higher in sugar and contains less fibre than modern wheat. Kamut kernels can be soaked overnight to reduce cooking time then simmered in a similar manner to rice for 30-40 minutes until tender.

Kamut can be used as an alternative to wheat flour in baked goods, or cooked in its wholegrain format as an alternative to rice or couscous, added to salads, soups or cooked into a porridge.

Quinoa Quinoa is a gluten-free grain originating from South America. It is low GI and packed with fibre, B vitamins and minerals, including magnesium, potassium, iron, calcium, phosphorous and zinc. A more commonly known ancient grain, quinoa can be used as an alternative to rice or couscous, added to soups, breads or cooked into a porridge.

Sorghum Sorghum is a gluten-free grain related to millet that originated in parts of Africa and Australia and can be grown in arid, infertile environments. It is low in GI and high in protein and fibre. It can be ground into flour and used in a variety of baked goods or boiled whole and eaten as a rice alternative.

Millet Millet is a small, seed-like grain believed to have originated in North Africa that grows well in arid, infertile environments. It does not contain gluten so can be eaten by people with coeliac disease or gluten sensitivities. It is a good source of protein, manganese, phosphorus, magnesium and fibre.

Different cooking methods can influence the texture of millet. When stirred frequently with plenty of water, it can develop a texture similar to mashed potato. If left unstirred, it will have fluffy grains similar to that of rice.

Spelt Spelt is a low-yielding grain of the wheat family, often linked with farro or emmer. Spelt is high in fibre and iron and is a source of protein, manganese, zinc and iron. Foods made from

Teff

Image: Rasbak, Wikimedia Commons

spelt often misleadingly claim to be gluten-free or better tolerated forms of gluten. Wholegrain spelt kernels can be soaked overnight to reduce cooking time. It can be boiled and used as a rice alternative, added to soups or ground into a flour for baked goods.

Teff Teff is a tiny grain made from the seed of an Ethiopian grass. It is gluten-free and packed full of nutrients including protein, magnesium, calcium, fibre, thiamin and iron. Teff is a versatile grain with a nutty flavour that can be eaten whole, ground into flour and used in baked goods or boiled into a porridge consistency. Traditionally it is ground into a flour and fermented in Ethiopia to make injera, a sourdough flatbread that is soft and thin like a pancake. conclusion

Dietitians can benefit from knowing nutritional differences between modern crops and ancient grains. As cooking methods and preparation techniques can impact nutritional quality and palatability, having the knowledge and skills to prepare ancient grains is important.

In their wholegrain format, consuming ancient grains can improve fibre, protein and micronutrient intake. As ancient grains become more mainstream and used as ingredients in every day food products, it is important for consumers to avoid being blinded by any health-halo effect this marketing buzzword may provide.

Information sources: www.cheerios.com/Products/Ancient%20Grains.aspx www.ucanr.edu/sites/Grown_in_Marin/files/131333.pdf www.greenwheatfreekeh.com.au/nutrition.php ndb.nal.usda.gov/ndb/foods

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on behalf of peng

Jacklyn Jones Senior Lecturer in Nutrition and Dietetics, PENG clinical Lead for Research and Audit, Queen Margaret University, Edinburgh Jacklyn has been a Registered Dietitian for over 25 years and worked in clinical practice for 14 years before moving to academia.

She has been involved with PENG in various roles since 1993.

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PENG: Supporting members in research and audit activities In the second article from the Parenteral and Enteral Nutrition Group (PENG) of the British Dietetic Association (BDA), Jacklyn Jones, takes a look at how PENG helps to improve engagement of dietitians in research and audit activities in order to encourage clinically effective practice.

There are increasing pressures across healthcare for all disciplines to demonstrate that they are clinically effective. Dietitians are not an exception to this. Indeed, there is a clear expectation that all dietitians should be involved in activities including audit1 and whilst this is also true of research, there is an acknowledgement that the level of research involvement will vary between dietitians. This can range from understanding, interpreting and applying research, through to leadership over significant research programmes and research supervision of others.2 The importance of being involved in research, audit, quality improvement and service development activities cannot be overstated in the current NHS, where evidence-based practice and outcomes are key priorities. This is, however, against the backdrop of healthcare workers having increasingly busy workloads resulting in the focus being on day-to-day patient care, with research and audit often seen as an addition to, rather than part of, current roles. This may explain why there have been reported barriers to dietitians participating in research and audit3,4 and so helping overcome these barriers is key to improving engagement of dietitians in research and audit activities.

If dietitians of all grades and at all stages of their career do not engage in research, audit, service evaluation and quality improvement activities, they will not be

www.NHDmag.com April 2016 - Issue 113

in a position to demonstrate that they are clinically effective practitioners.

The cornerstone to clinically effective practice is ensuring that the service provided by healthcare practitioners is evidence-based, i.e. is founded on a strong research base and that measuring the care given provides a means to demonstrate the quality of the service, i.e. is subject to regular audit. Basing care on these principles provides dietitians with the opportunity to deliver the best care for their patients whilst delivering value for money.

Due to ongoing developments in healthcare, dietitians can often find themselves in a position where they may be unsure how to best manage a patient and often searching the literature does not provide the full answers to the questions we have. These shortfalls, however, could be turned into opportunities to undertake work to fill the gaps in the evidence base.

Many dietitians have expressed an interest in being more involved in research and audit, but anecdotal evidence suggests that, for many people, taking those first steps into research can be daunting. In addition, many people will have a plethora of patient data which would be of interest to other dietitians, but this information is often not shared as people may not know the best way to disseminate this information.

In light of these findings, PENG set out to better support members to

The committee and Clinical Leads worked together to develop a research strategy that would guide our activities. The first aim identified was to establish current engagement in research and audit type activities of PENG members overcome some of the barriers to engaging with research and audit to enable us, as a profession, to further develop the evidence base around nutrition support. To help facilitate this, the PENG committee was restructured in February 2014 to include a small core committee supported by a number of clinical lead roles. My role is to act as clinical lead for research and audit. The focus of this role is to support PENG members to develop their research and audit skills and in turn to enhance the evidence base in the area of nutrition support. In view of this and based on PENG’s commitment to promoting excellence in nutrition support, enabling the PENG membership to develop and increase research and audit activities was considered a key strategic goal.

The committee and Clinical Leads worked together to develop a research strategy that would guide our activities. The first aim identified was to establish current engagement in research and audit type activities of PENG members, to determine the barriers to undertaking these activities and to establish the need for support mechanisms for members to become more engaged. An online survey was developed by the PENG committee and circulated to all PENG members in April 2014. Sixty nine of 386 PENG members completed or partially completed the survey and of these, all agreed or strongly agreed that audit was an important component of the role of a dietitian.

Fewer respondents (n=60 (87%)) agreed or strongly agreed that research was an important component of a dietitian’s role. The majority of respondents (n=65 (97%)) were, or had been involved in audit and 46% (n=31) were or had been involved in research. Of those people who reported that they had never been involved in research and audit the main reasons were lack of time (n=11), lack of confidence (n=5), lack of critical appraisal skills (n=4) and lack of support (n=4). The survey also found that results of research, audit and service evaluation activities

were generally disseminated locally within dietetic departments (n=50), via articles for local newsletters or oral and poster presentations at a local meetings (n=44), with fewer respondents disseminating results as an oral presentation or a poster nationally (n=30) or internationally (n=13). The majority of respondents (n=44 (72%)) stated that they would like to be more involved in research and audit and 64% (n=40) reported that they had an idea for a project in the area of nutrition support but they had not yet started it. Almost all respondents indicated that they would value support in undertaking such projects and the most commonly cited areas of support were funding for backfill (n=54 (78%), help with statistical analysis (n=42 (61%)), help with writing proposals (n=33 (48%)), help with writing for publication (n=31 (45%)), along with a variety of other related activities. (Full results of this survey are available in e-penlines autumn/winter 2014.)

The results from the survey were utilised to shape and inform the research and audit activities of PENG. To this end, PENG ran a very successful study day in November 2015 covering many aspects of undertaking research, audit and service evaluation projects. The day included three key note presentations. Dr Judy Lawrence, BDA Research Officer provided a succinct overview of the national facilitators for research and audit which included sources of funding which could help with salary backfill and the execution of studies. She also emphasised the assistance available from BDA Head Office.

Mel Baker, Senior Specialist Dietitian, Leicester Intestinal Failure and Feeding team, gave an eloquent overview of her journey in the research arena, including her success in securing an NIHR grant and PENG funding. Anne Holdoway provided excellent tips on effective presentations to enable participants to consider how they might effectively communicate their results and key messages. www.NHDmag.com April 2016 - Issue 113

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on behalf of peng

These initiatives are the beginning of what is hoped to be ongoing work by the PENG committee to respond to the needs of the PENG membership and to support them in developing their practice.

In addition to these keynote presentations, the six PENG award winners shared the results of their research and audit projects which covered a range of nutrition support topics. These presenters had all been awarded one of the annual PENG education awards which are supported by industry (Nutricia, Fresenius-Kabi, Abbott).

The projects presented illustrated the breadth of the profession’s work and provided excellent examples for the audience on the fruits of one’s labour. The remainder of the day was a facilitated workshop where the delegates enthusiastically participated in activities to turn data into abstracts and reports. The day was evaluated highly and many delegates were motivated to return to their work place and either commence projects or to consider the dissemination of results from previous projects. It will be great to see the publication of some of these projects.

In addition to the study day, other initiatives have been developed to support the PENG membership in research and audit activities. One development is the provision of small project grants. PENG now awards small grants to their members to undertake research, audit and service evaluation in the area of clinical nutrition and nutrition support. PENG members can apply for money to support aspects of running a project including project costs, equipment, consumables, help with backfill and even to support study at post graduate level. These should be in the area of clinical nutrition or nutrition support. In the past year, one PENG member (Mel Baker) has been successful in securing £4,100 to undertake a retrospective audit of the management of high output stomas. Mel is currently working on the

audit and will provide a report to PENG and hopefully present and/or publish the results when the study is complete. More details of this scheme are available to PENG members on the PENG website: www.peng.org.uk A further initiative is the development of a mentorship scheme. The membership survey identified that whilst many PENG members would like formal training in research and audit type activities, many stated that they would find it beneficial to have an individual point of contact to ask specific questions about the research and audit process. Experienced researchers have volunteered to become mentors and offer help and support to those people who have requested it. This scheme is in its infancy, but the intention is to match mentors with people looking for support, either based on areas of expertise or by location - whichever is the most appropriate. It is envisaged that mentors could provide ongoing support over longer periods, or could provide one-off pieces of advice/support.

These initiatives are the beginning of what is hoped to be ongoing work by the PENG committee to respond to the needs of the PENG membership and to support them in developing their practice. It is fabulous to see so many PENG members already engaged in research and audit activities and to see many more becoming involved. These are exciting times for dietitians to be involved in research and audit activities and there are significant opportunities for the profession to develop their practice and demonstrate that we provide a fundamental service within a health and social care environment.

References 1 Health and Care Professions Council. (2013). ‘Standards of proficiency - Dietitians. HCPC, London 2 British Dietetic Association (2007). Dietitians and Research: A knowledge and Skills Framework. Birmingham: BDA 3 Harrison JA, Brady AM and Kulinskaya E (2001). The involvement, understanding and attitudes of dietitians towards research and audit. J Hum Nutr Diet. 14, 319-330 4 Gardner JK, Rall LC and Peterson CA (2002). Lack of multidisciplinary collaboration is a barrier to outcomes research. J Am Diet Assoc 102, 65-71

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web watch

web watch Online resources and useful updates.

Visit www.NHDmag.com for full listings.

NICE Guideline/ Standards update

Irritable bowel syndrome in adults. NICE quality standard [QS114]

Published February 2016.

This quality standard covers the diagnosis and management of irritable bowel syndrome in adults. It does not cover other gastrointestinal disorders such as non-ulcer dyspepsia, coeliac disease and inflammatory bowel disease. Quality statement 3 discusses the dietary management of IBS. Available at www.nice.org. uk/guidance/qs114

Motor neurone disease: assessment and management.

NICE guidelines [NG42]’ This guideline covers assessing and managing motor neurone disease (MND). It aims to improve care from the time of diagnosis and covers information and support, organisation of care, managing symptoms and preparing for end of life care. Nutrition, hydration and gastrostomy are discussed in 1.10 of Managing Symptoms within this guideline. Available at www. nice.org.uk/guidance/ng42

Food Standards Agency update: preventing food allergy On 04/03/16 the FSA shared the news that a major new study had

been published in the New England Journal of Medicine, which has found that introducing allergenic foods to the infant diet from three months of age may be effective in food allergy prevention if the recommended quantity of allergenic food was consumed. This research is the outcome of the EAT (Enquiring About Tolerance) study, which was funded by the FSA and Medical Research Council. It was conducted by King’s College London with the support from St George’s University of London. A summary report of the EAT study is now available via the FSA website: www.food.gov.uk/news-updates/ news/2016/14958/giving-allergenicfoods-to-infants-from-three-monthsold-may-prevent-allergies

Journal of Human Nutrition and Dietetics: new systematic reviews Two new systematic reviews have been published on the estimation of energy expenditure using predictive equations in overweight and obese adults. Published on 29/02/16 the objective was to identify which equations based on simple anthropometric and demographic variables provide the most accurate and precise estimates of (1) resting energy expenditure (REE) and (2) total energy expenditure (TEE) in healthy obese adults. The reviews found no single prediction equation provides accurate and precise REE estimates in all obese adults. Mifflin equations are recommended in this population, although errors exceed

10% in 25% of those assessed. There is no evidence to support the use of prediction equations in estimating TEE in obesity. http://onlinelibrary. wiley.com/doi/10.1111/jhn.12355/ abstract.

Reference: Madden AM, Mulrooney HM, Shah S (2016).

Estimation of energy expenditure using prediction equations in overweight and obese adults: a systematic review. J Hum Nutr Diet. doi:10.1111/jhn.12355

NHS Choices resources Superfoods: the evidence A useful resource which looks at the evidence behind health claims surrounding 10 ‘superfoods’ such as blueberries, beetroot juice, chocolate, garlic and goji berries. The resource has been developed with the BDA (British Dietetic Association) to provide an easy-to-read-and-use format to highlight the evidence (or lack of!) for labelling these foods as ‘superfoods’. www.nhs. uk/Livewell/superfoods/Pages/ superfoods.aspx Ask for the evidence!

An online resource, ‘Ask for evidence’ provides support for young people to develop skills to critically assess online claims and reduce sharing of poor quality, unquestioned information. The easy-to-use website allows young people to become savvier when reading about product claims, policy statements, newspaper articles and adverts. Requesting the evidence behind these publications is encouraged and supported by the site. http://askforevidence.org

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49

CAREER

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

R&D Dietitian - Clinical Science Team – Vitaflo Full-time, permanent. Based in Liverpool. Vitaflo International Ltd is looking for a dynamic and highly motivated dietitian to join its Clinical Sciences Team with Research and Development. We are offering a full-time position in our head office in Liverpool. We are seeking someone who will thrive in a dynamic, innovative environment, who has excellent communication skills, is flexible, self-motivated and enthusiastic. In return, we offer a competitive remuneration package. Full training will be provided but clinical experience, particularly in metabolic disorders, renal disease, ketogenic diet and general paediatrics would be a definite advantage.

Previous industry experience would also be advantageous but not essential. Please e-mail your CV to chris.richards@ vitaflo.co.uk, or alternatively post to: Mr Chris Richards, HR advisor, Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool L3 4BQ.

Jobs from Elite Recruitment Acute Paediatric Dietitian - Essex Band 7 Acute Paediatric Dietitian is required for a hospital in Essex. This role is full time starting asap for at least five months, covering a maternity leave. Must have experience with Neonates.

Acute Dietitian Band 6 - Kent Band 6 Dietitian required to work in an acute role in Kent, full time hours for at least three months. This position will be covering a renal caseload so the candidate would ideally have experience with renal patients. If not, then at least two years’ acute experience is required..

Dietitians wanted – NW England We are looking for a Band 5 or 6 Dietitian to join this community position in the North West of England, we require either 20 hours (Band 5) per week or 16 hours (Band 6) per week, starting April initially for 12 weeks.

This role covers adult community work and home visits, so own transport is desirable.

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.

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events and courses University of Nottingham School of Biosciences

Modules for Dietitians and other Healthcare Professionals • Nutrition Support (D24BD2) 20th April (International Students only), 21st, 27th & 28th April

• Obesity Management (D24BD3) 6th & 7th October & 8th & 9th December

• Gastroenterology (D24GE1) 13th & 14th October & 15th & 16th December

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

Royal Marsden Study Day • Nutrition and Cancer: What Patients want to know - 18th May

A study day aimed at dietitians, nurses doctors and other healthcare professionals working with cancer patients. There is a wealth of information on diet and cancer, not all of it based on good scientific evidence. This study day will look at popular areas of nutrition and cancer and untangle the myths from the evidence. It will focus on topics frequently raised by those with cancer. Book online: www.royalmarsden.nhs.uk/nutritionalcare

Royal Society of Medicine 1 Wimpole Street, London W1G 0AE

• Research methods and critical appraisal course 24th Jun, 23rd Sep & 26th Nov - 10am to 4.30pm 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.

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.

The topic for this issue underwent a last-minute change when I was informed of some breaking news by the NHD ‘Head Office’ . . .

This concerned the decision by George Freeman, Minister for Life Sciences, to introduce supplementary prescribing by dietitians across the United Kingdom.

The Medicines and Healthcare Products Regulatory Agency (MHRA) will now need to make the necessary amendments to medicines legislation.

Eligible practitioners, advanced level and experienced dietitians must successfully complete a Health and Care Professions (HCPC) approved post graduate education and training programme and have this qualification marked against their name on the professional register before they can access these powers.

The legislation has been three years in the making, as, since October 2013, NHS England has been working closely with the Department of Health, the MHRA and our professional body, the BDA. The consultation process lasted for eight weeks and was completed in April 2015.

However, the recognised need for change by the dietetic profession goes back much further.

Registered dietitians working in long-term conditions, such as diabetes,

chronic kidney disease, cystic fibrosis and parenteral feeding, were finding that delays in treatment were occurring as a result of medications needing to be approved by a busy medical profession.

The consultation on dietitians said, “The frustration amongst doctors and patients alike is that the current system requires the patient’s consultant or GP to initiate and adjust medicines as advised by the dietitian in a separate additional appointment/consultation. Delays are inevitable.

“It is always frustrating when GPs find their time being used to ‘rubber stamp’ clinical decisions which have quite appropriately been made by our colleagues.”

I am aware that the prescribing project team at the British Dietetic Association, led by Policy Officer Najia Qureshi, has been working tirelessly on this important issue for close to 10 years. I would commend them for their diligence and their achievement in getting the profession recognised in this way for the benefit of both practitioners and patients.

I look forward to seeing the new post graduates in 2017. Well done.

Public Health England launches ‘One You’ campaign PHE have launched a ground-breaking new campaign to help adults across the country avoid future diseases caused by unhealthy lifestyle and diet choices because of modern life. Eating too many unhealthy foods, excessive alcohol consumption, limited physical activity and smoking are all responsible for approximately 40% of all deaths in England, with a cost of more than £11 billion each year to the NHS. The ‘One You’ campaign aims to encourage adults, particular middle-aged adults, to make healthy lifestyle and dietary changes to enjoy health benefits both not and in later life. A new online health quiz called ‘How Are You’ is available to provide personalised recommendations based on a person’s results. It will direct people to tools and advice to help them take action where it is needed the most. www.nhs.uk/oneyou

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51

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NHDmag.com

April 2016

ULCERATIVE COLITIS PART 2

MODERN DIETARy TREATMENT A REVIEW OF THE OLDEST BOOK ON DIETETICS

BY URSULA ARENS

Editor's report

NHD-Extra: book review

Going forward (by looking back to dietetics in the 1930s) Modern Dietary Treatment by Elsie Widdowson and Margery Abrahams is 79 years old, but still offers a lot to think about in one of the first books on dietetics.

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

Dr Margaret Ashwell, OBE, PhD, FAfN, RNutr (Public Health), Research Fellow Dr Margaret Ashwell has been a Senior Research Scientist with the Medical Research Council, Science Director of the BNF and an Independent Consultant, working for government and industry. She is an author and editor of the biography of the nutrition pioneers, McCance and Widdowson. She was appointed an OBE in 1995 and was elected as a Fellow of the Association for Nutrition (AfN) in 2012.

The first issue of Modern Dietary Treatment was published pre-war in 1937, and we are most fortunate to have the original Elsie-Widdowson annotated copy that would have been given to the publisher to form the basis of a later update. Edition Two appeared in 1940 and the final third edition was published in 1951.

The introduction to the book cheers the rapid advance in the science of nutrition from about 1910. These include revolutionary developments in knowledge about vitamin and mineral metabolism and improvements in food analysis. The vitamin researchers in the first third of the last century were the intellectual heroes of the time: Frederick Gowland Hopkins could match Bill Gates-today for acclaim and the Cambridge nutrition department outputs were unrivalled for pioneering science concepts.

Elsie, who was a biochemist at Kings College Hospital and Margery Abrahams, who was a dietitian at St Barts Hospital, authored the first edition of Modern Dietary Treatment.

In the first correction in the book, there is the update that Elsie was now at the Department of Medicine in Cambridge.

The first chapters cover basic dietary principles. Later chapters are more applied to discussion about diet modification in relation to disease states.

High and low Calorie diets, invalid diets, diets for diabetes or diseases of kidney and alimentary systems, and diets for mineral metabolism disturbances all get

individual chapters. As does the topic of diets for Jewish patients. Large final sections of the book describe diet food lists, recipes and food composition data.

There are revealing errors, which perfectly capture the developments of our understanding of nutrients.

So, for example, it is asserted that the iron in meat is mainly in a form that is unavailable to the body; today we would consider the opposite to be the case. Another example of muddle is some of the statements about the B vitamins. While many vitamin B forms had been described, Elsie and Margery stated that only B1 and B2 (described as vitamin B and vitamin G in America) were needed in humans. The name for B2 is given as lactoferrin (now riboflavin), and the American vitamin ‘G for Goldberger’ was actually what is now described as the anti-pellagra vitamin niacin. The vitamin B complex is, complex, and these inaccuracies show the difficulties in trying to capture the state-of-knowledge at the time.

The first edition has no mention of vitamin E, but the handwritten paper insert updates this section for the next edition. Deficient status results in fetal resorption in pregnant rats, but whether vitamin E deficiency had any connection www.NHDmag.com April 2016 - Issue 113

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FOOD AND NUTRITION

The chapter on diabetes diets is the most interesting one for history-of-nutrition enthusiasts.

with habitual abortion in humans had not been satisfactorily proved. Vitamin E is still the vitamin most looking for a function (in human nutrition).

There are delightful statements in the book that would surprise dietitian readers of today.

Such as the warnings about diets containing large amounts of vegetables - these are wasteful for normal people since they tend to displace more concentrated and nourishing foods.

Such as comments on the challenges of giving advice to diabetic patients who are, ‘elderly or stupid.’ Such as snack suggestions for those with anaemia: toast with minced hog’s stomach - not doubt an effective measure, but a culinary challenge today.

The chapter on diabetes diets is the most interesting one for history-of-nutrition enthusiasts. While 1921 is the search-google year for the discovery of insulin, there were fierce debates over carbohydrate control, and Elsie and Margery describe these. Pre-insulin days meant starvation and then feeding high fat diets, and then very incrementally increasing amounts of carbohydrate, until a tolerance level was achieved. However, it appeared that even in the mid-1930s ‘Newburgh and his followers in America and many continental doctors’ still advocated very low carbohydrate diets for blood glucose control. For dietitians and doctors who 3

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supported greater intakes of carbohydrate, there was much confusion on diets. Thankfully, Dr RD Lawrence published the Line Ration diet scheme in 1936, which gave lists of interchangeable foods containing 10g units of carbohydrates. This dramatically simplified communication about the diabetic diet, with black line foods for carbs and red line foods for proteins and fats. Page 185 of the book is the only one printed in colour, and ‘going red’ must have been a debated and costly publishing decision.

Many therapies described in Modern Dietary Treatment are lost and long forgotten: Sherman, Lenhartz and Epstein diets ring no bells in nutrition discussions of today. It is also amazing that there is no single reference in the book to the terms allergy, gluten, or saturated fats. Today’s demon, sugars, is only described as an attractive and useful way to add energy to the diet of a child or invalid.

There have been explosive expansions in nutrition science data available for dietetic professions to consider in optimising health in the pre- and post-diagnosed. But all of these must still be funnelled into on-the-plate choices, which for most people, of course, are mainly driven by many other factors. But Elsie and Margery’s book considers just these issues, and they will be the same issues needing expert guidance in the future.

NHD-Extra: CONDITIONS & DISORDERS

case study: ULCERATIVE COLITIS (IBD) The impact of IBD on the nutritional status and life of an 18 year old Emma Coates NHD 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.

Part 1 of this article can be found on page 35 of this issue.

Part 2: Post-surgical experiences, diet with an ileostomy and the ileoanal pouch

Case Study Part 2 It was dark, she had no idea what time it was. For a minute, she wasn’t sure where she was, but it all came flooding back. Lying in a bed, propped up a little and surrounded by beeping machines. Wires and tubes to the left and right of her. The cannula in her left hand pulled a little as she tried to scratch her nose. Looking around the room, she felt a similar pull in her neck. Another cannula in the left of her neck. It made her shiver a little. Remembering why she was there, she patted her abdomen, expecting it to be tender.

No pain, nor discomfort, just the rustle of the new ileostomy bag and the large white dressing on her surgical wound. The nurse came in, ‘Well hello, you’ve been sleeping.

Don’t you worry; we’ll get you back on your feet in no time’. Maria smiled and nodded off again . . .

Maria stayed on the High Dependency Unit for three days after her surgery (a restorative proctocolectomy with ileoanal pouch construction and temporary ileostomy; see Part 1 of this case study in NHD April 2016, for more information about this procedure). In the weeks preceding the surgery she was introduced to a specialist stoma care nurse who explained the surgical procedure to Maria and her family. She was able to answer the many questions Maria had about life with an ileostomy. What will it look like? Will she feel it? How big are the bags? Will it smell? The list went on. Following her surgery, the stoma care nurse reviewed Maria on the ward and after a few days, as Maria was able to get up and walk around, she went through changing the bag and how to care for the skin around the stoma. In the few days following the surgery, Maria hadn’t been eating well, therefore her stoma output had been limited. However, as she gained her appetite back, she found many foods resulted in higher outputs than others; for example, high fibre cereal and fruit. In addition, the effects of some foods were particularly malodourous and this was not pleasant. For the first five days post-surgery the output was quite liquid. However, the consistency improved and could be described as toothpaste or porridge consistency (type 6 stools7).

Initially, the bag required emptying every two to three hours, but as things settled over the week following the surgery, this reduced to approximately three to four times per day. Please see Table 1 for an overview of some of the dietary considerations with an ileostomy.

As Maria’s weight had dipped to 45kg (BMI 16.3kg/m2) prior to surgery, she was referred to the dietitian by the ward nursing staff. She was prescribed 3 x 220ml milkshake style, 1.5kcal/ml oral sip feeds per day. Maria initially struggled to consume all three of the sip feeds each day, but once she was discharged home, this became easier and she continued to take them for approximately three months. She made the decision herself to discontinue them as she was

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NHD-Extra: CONDITIONS & disorders Table 1: Dietary considerations with ileostomies In the main, most people with an ileostomy can manage a normal diet.1 In the first few weeks after surgery, most patients require a low-fibre diet. A high-fibre diet can increase the size of stools, which can cause the bowel to become temporarily blocked. After around eight weeks, a normal diet can be introduced.2 Reintroducing foods

A healthy, balanced diet, including plenty of fresh fruit and vegetables (at least five portions a day) and wholegrains, should be encouraged. Patients may reintroduce new foods slowly after surgery. There may be long-term anxiety around eating some foods, especially after many years of avoiding them due to GI symptoms. Introducing at the rate of one new food at each meal may be agreeable. This will allow patients to judge the effects of the food. Keeping a ‘food/symptom diary’ may be useful.

Wind/flatulence/bloating

Some foods may cause wind, e.g. beans and pulses, brassica vegetables, onions, nuts and eggs. Fizzy drinks and beer also cause wind. These may be best avoided or kept to a minimum. Fennel and peppermint tea may help to reduce wind. Skipping meals may make the problem worse.2

Malodourous/smelly stools

Some food may create malodourous stools, e.g. fish, eggs, spiced foods, cabbage. Many people worry that their bag will smell. However, all modern appliances have air filters that have charcoal in them, which neutralises the smell. Special liquids and tablets that are placed in the bag are available to reduce any odour.

Diarrhoea

A high fibre intake, spicy or fried foods, alcoholic or caffeinated drinks may cause diarrhoea. Fruit juices, fresh or dried fruits, vegetables and salads are also possible causes. Some sweets and cakes are sweetened with sorbitol.

This may have a laxative effect for some patients. Some patients may still require antidiarrhoeals to manage loose stools.

Dehydration

As the re-absorb of water and minerals within the large intestine is now absent, there is a greater risk of dehydration. A good fluid intake is advised, particularly in hot weather or during activities or sports. Rehydration powders my help to reduce dehydration.

Undigested food

Soft, well-formed stools are usually formed in the large intestine. In its absence, patients may experience looser stools containing undigested foods, such as, sweetcorn, peas, mushrooms, apple, carrot etc. These are generally harmless, but patients should be advised to chew these foods well and even slitting the skins/kernels on peas and sweetcorn. Rarely, these foods can cause a blockage of the stoma.

Foods to improve symptoms

5

To reduce output/improve stool consistency

Cheese and yogurt Mash potatoes, boiled rice or pasta Marshmallows or Jelly babies Creamy peanut butter Ready Brek or porridge Toast half and half/ 50:50 bread may be better tolerated Apple sauce/cooked apple Ripe banana

For nutrition support

Full fat milk - aim for one pint per day in drinks or added to food.

Add extra olive oil or margarine to meals.

Eat little and often - aim for six small, high calorie meals and snacks per day.

Encourage milk puddings such as sago, semolina, yoghurt or rice pudding.

Encourage milky drinks such as hot chocolate, Ovaltine, Build-Up or Complan, or prescribed sip feeds.

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eating well and felt that the sip feeds were dampening her appetite. For almost nine months, Maria had her ileostomy. She gained 5.0kg in weight and her BMI increased to 18.4kg/m2 (weight 50kg, height 1.65m). The ileostomy had given her a new lease of life. She was free from abdominal pain and her appetite had improved significantly.

During the time with her ileostomy, Maria was able to introduce a fairly normal and healthy diet. She was managing five portions of fruit and vegetables per day and some higher fibre foods, such as Weetabix, wholemeal bread and baked beans. She avoided highly spiced foods, fizzy drinks, alcohol and some vegetables such as celery, sweetcorn and onions, as these caused her excessive wind and looser stools. She was more energetic and she was able to sleep well, which made a huge difference to Maria’s general wellbeing and allowed her to take on a few hours of volunteering work at a local charity shop. Although she remained self-conscious about her health issues and her ileostomy, she was able to engage in social events with her peers and family.

Nine months on with her ileostomy, Maria was reviewed via a water-soluble enema and ultrasound scan (loopogram)3,4 to ensure her ileoanal pouch had healed and she was suitable for the reversal of the ileostomy. This procedure showed that the pouch had healed and Maria was booked in for her ileostomy reversal two weeks later.

Following the reversal operation, Maria returned to the ward. She was anxious and elated at the same time. In many ways, she was pleased that the ileostomy was reversed, but she was concerned that she would be passing stools via her anus for the first time in nine months. Again, she had so many questions rush through her head. Will she have continence? Will she be in pain again? What if she can’t control her bowels? Her stoma care nurse was able to answer some of these questions.

Table 2: Complications in UC and ileoanal pouch patients Toxic megacolon

A rare but serious complication of severe ulcerative colitis.

Inflammation in the large intestine becomes swollen due to trapped gas caused by inflammation.

It can cause a sudden drop in blood pressure, resulting in shock.

The bowel can rupture and septicaemia can occur.

Symptoms include abdominal pain, pyrexia and tachycardia.

Treated with intravenous fluids, antibiotics and steroids.

The trapped gas can be drawn out via the insertion of a small tube in to the rectum and large intestine.

In severe cases, surgery may be required, where the large intestine is removed (colectomy).

Rectal or colon cancer

Patients with long term (10 years or more) severe UC have an increased risk of colon or rectal cancer.

Symptoms of this type of cancer can be masked by UC as they are similar blood in the stool, diarrhoea and abdominal pain.

Regular gastroenterology reviews and monitoring of symptoms should be provided for long-term UC patients.6

Osteoporosis and osteomalacia

Osteoporosis and vitamin D deficiency are common in IBD. Major risk factors include older age, steroid use and disease activity.6

Anaemias

Iron deficiency is common in IBD patients. Regular haemoglobin, ferritin, transferrin saturation and CRP checked should take place.6 There is also an increased risk of folate or B12 malabsorption in after surgery where the ileum has been involved. www.NHDmag.com April 2016 - Issue 113

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NHD-Extra: CONDITIONS & disorders Table 2 continued Obstruction/blockage

Patients undergoing pouch surgery for UC are at high risk for small bowel obstruction due to the combined abdominal and pelvic dissection.

Postoperative adhesions, a twisted intestine, herniation of the bowel, or twisting of an ileostomy may result in partial or complete small bowel obstruction.

After closure of a temporary ileostomy, obstruction may also occur due to luminal stenosis or adhesions at the closure site.7

Pouch leakage or bleeding

Soon after surgery, leaks and bleeding may develop from any part of the newly formed pouch, along the suture lines and anastomosis site (ileum to anus).

Elderly patients, males, and those on corticosteroids are at greater risk.

Pouch ischemia is rare and is characterised by copious dark red blood with clots.7

Pouchitis.

A longer-term complication, acute or chronic inflammation of the ileal reservoir (pouch).

Symptoms include increased stool frequency and urgency, abdominal pain, bloody diarrhoea, fever, faecal incontinence.

Treated with antibiotic therapy, e.g. metronidazole and ciprofloxacin.

Antidiarrheal drugs to manage stool frequency and urgency.

Once again, Maria was advised by the stoma care nurse to alter her diet to manage any symptoms. This time she was more anxious about eating, as she was concerned she wouldn’t be continent. She opened her bowels for the first time almost two days after the reversal surgery.

She passed a type 7 stool,5 but she was continent and pain free. She was extremely relieved by this. However, for five days after the surgery, Maria struggled to eat anything more than white bread toast and butter, tea with milk and salt and vinegar crisps. She was still anxious to introduce any higher fibre foods, fruits or vegetables. Her stoma care nurse asked her to speak to a fellow patient on the ward who had undergone similar surgery and who was eating well. Maria enjoyed speaking to this patient, an older woman, in her 40s. Hearing the positive experiences this patient had had when introducing foods back in to her diet gave Maria some confidence to try some different foods. She introduced porridge, ham and chicken, potatoes and cooked vegetable such as carrot, parsnip and butternut squash.

She was discharged home after seven days on the ward. Although she needed to open her bowels eight to 12 times per day as she increased her dietary intake, she was able to maintain continence and her stools thickened, often passing type 5 stools.5 She continued to avoid many of the foods and drinks she hadn’t tolerated whilst she had her ileostomy.

After three to four months, Maria’s pouch activity had settled and she was opening her bowels six to eight times per day, with continued type 5 stools.5 Once again she was managing five portions of fruit and vegetables per day; she was also including higher fibre version of breakfast cereals and bread. She considered her diet relatively normal. Her weight had improved again and she was now 56kg, BMI 20.5kg/m3. Three months after her reversal operation, Maria enrolled again at her local sixth form college. She was keen to return to her studies and she felt healthy for the first time in nearly three years. She was able to engage in all of the social and even sporting activities on offer with her peers. She started to play badminton at a local club and she enjoyed swimming two to three times per week. In the two years following her surgeries, Maria remained well for the majority of the time, but she experienced two episodes of pouchitis. See Table 2 for a more information on pouchitis and other complications of UC and pouch surgery. She was successfully treated with courses of antibiotic therapy, including metroniozole and ciprofloxacin.

Ulcerative Colitis, like many chronic diseases, has a major impact on a patient’s life. Maria not only experienced significant health problems because of this condition, but her social and mental 7

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health was affected too. In addition, she confronted several dietary challenges, due to physical and psychosocial factors. There is little research available regarding the psychosocial factors of food and the impact that IBD has on quality of life. A study conducted by Hughes et al8 in 2013, found that in patients with active IBD disease, there were psychosocial issues relating to food and drink. Self-imposed dietary restraints influenced daily eating and drinking, as well as social relationships. Patients with IBD opt to make changes in their diet to control their symptoms and compromises are made when eating with friends and family. Quality of life is often reduced, but little was known about the strategies used by patients to manage these issues. Further research is underway to investigate this, with plans to develop a food-related quality of life questionnaire, which could be used in clinical and research settings. For more information visit - www.kcl.ac.uk/ ioppn/depts/psychology/research/ResearchGroupings/healthpsych/research-group/IBD.aspx <accessed 03/03/16> The management of IBD is only successful through high quality MDT working. The Royal College of Physicians has recently published a report9 following an audit of IBD services across the UK, looking at areas for improvement in IBS services, but also areas where action has been take or starting to take place. The report includes data from eight regional workshops attended by 258 delegates (including eight dietitians) from 84 trusts and health boards. 125 individual action points were recorded and grouped into 24 themes. The five most common action themes were: 1 patient pathways - biologics, diagnostic, inpatients, pregnancy, standardised care, policy/ protocol and shared care 2 IBD nurses 3 IBD Registry/database 4 patient panel/group 5 multidisciplinary team meetings Dietetic and nutritional support improvement targets were included with some progress being made. This report is the work of The IBD programme team, which was established over 10 years ago. Their aim is to improve the quality and safety of care for people with IBD throughout the UK. Initially, the team audited IBD services to highlight variations across the UK. In recent years, the team has evolved and their work includes a wider range of quality improvement measures and supporting the development of national standards for IBD care. Find more information about the work of the IBD programme at www.rcplondon.ac.uk/ibd.

References 1. The Ileostomy and Internal Pouch Support Group (2016). Ileostomies and Eating Habits. www.iasupport.org/about/publications/factsheets/ileostomiesand-eating-habits 2. NHS Choices (2016). Living with an ileostomy. www.nhs.uk/Conditions/Ileostomy/Pages/Recommendations.aspx 3. Ramakrishnan K, Scheid D (2002). Opening Pandora’s Box: The Role of Contrast Enemas in Abdominal Imaging. The Internet Journal of Gastroenterology. Volume 2 Number 1. Available at http://ispub.com/IJGE/2/1/13573 <accessed 03/03/16> 4. Bickston SJ and Bloomfeld RS (2011). Handbook of Inflammatory Bowel Disease. Lippincott Williams & Wilkins, Philadelphia. Chapter 22, pp 23 5. Heaton KW and Lewis SJ (1997). Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology, Vol 32, no 9, pp 920-924 6. Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, Driscoll R, Mitton S, Orchard T, Rutter M, Younge L, Lees C, Ho G, Satsangi J, Bloom S. On behalf of the IBD Section of the British Society of Gastroenterology (2011). Guidelines for the management of inflammatory bowel disease in adults. Available at www.bsg.org.uk/images/stories/docs/clinical/guidelines/ibd/ibd_2011.pdf <accessed 03/03/16> 7. Gorgun E and Remzi FH (2004). Complications of Ileoanal Pouches. Clin Colon Rectal Surg. Feb; 17(1): 43-55 8. Hughes LD, Lindsay J, Lomer M, Myfanwy M, Ayis A, King L and Whelan K (2013). Psychosocial impact of food and nutrition in people with Inflammatory Bowel Disease: A qualitative study. British Society of Gastroenterology conference. Abstract available at https://kclpure.kcl.ac.uk/portal/ en/publications/psychosocial-impact-of-food-and-nutrition-in-people-with-ibd-a-qualitative-study(1ab5dafc-3035-49e3-918f-ccd6f99370b4).html <accessed 03/03/16> 9. Royal College of Physicians (2016). Inflammatory Bowel Disease Programme. Improving quality in IBD services: UK inflammatory bowel disease audit.

PDF available at http://s3-eu-west-1.amazonaws.com/files.crohnsandcolitis.org.uk/Publications/PPR/improving-quality-in-IBD-service.pdf <accessed 03/03/16>

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EVENTS

BDA LIVE 2016 - EDITOR'S REPORT Emma Coates NHD 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.

The 16th and 17th March 2016 saw the return of BDA Live, an extra special couple of information-packed days held at the QEII Conference Centre in London. This year the BDA is celebrating its 80th birthday!

The 16th and 17th March 2016 saw the return of BDA Live, an extra special couple of information-packed days held at the QEII Conference Centre in London. This year the BDA is celebrating its 80th birthday!

In order to celebrate 80 years of Dietetics, the BDA provided a broad ranging agenda for delegates over the two days, which was supported by a wealth of experienced dietitians and numerous exhibitors, including Abbott, Nutricia, SMA, Vitaflo International Ltd, Yakult Ltd and Oatly, plus many more.

The key messages throughout the event clearly encouraged all dietitians to be proud of their profession and to share our unique knowledge and expertise whenever we see the opportunity. This year, the BDA was not only looking back at its achievements, but was also looking forward, with many sessions focusing on innovation, driving services forward and ensuring that Dietetics has a strong future within our healthcare system.

LEADING THE WAY Day one opened with an excellent plenary session looking at malnutrition and dehydration across the healthcare system and how Dietetics is leading the way forward. Keynote presentations focused on the implications of new guidance, commissioning services, the role of

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nutrition in cancer care and gluten-free food provision in healthcare. Concluding the session, Kirstine Farrer Consultant Dietitian from Royal Salford NHS Trust Foundation, gave a talk regarding the piloting of a Malnutrition Task Force in the Salford area.

This was followed by a panel discussion involving the session speakers, where effective strategies for optimal nutritional care were considered.

After lunch, a choice of two specialist group-led breakout sessions were available.

Sports and Exercise Nutrition Register (SENr) hosted one of these sessions, which included presentations on performance nutrition, the role of milk proteins in sport training and exercise, also how biomarkers can be used in the modification of elite athlete’s nutritional programs.

The Parenteral and Enteral Nutrition Specialist Group (PENG) hosted and alternative session, where the importance of outcomes and communicating those outcomes were highlighted and discussed.

The PENG group session also included presentations, which looked at the successes and experiences of others when looking at outcomes.

This year’s Creina Murland Memorial Lecture was presented by Professor Anita MacDonald OBE, PhD, Consultant Dietitian in Inherited Metabolic Disorders, Birmingham Children’s Hospital.

Anita shared her experiences and thoughts on leadership in Dietetics. Day one was rounded off with a drinks reception to celebrate the BDA’s 80th birthday which included a number of award presentations including, the annual Dame Barbara Clayton award, along with special memorial awards for Pamela Brereton and Pat Judd.

THE EARLY BIRD CATCHES THE WORM!

Pre-lunch, Abbott offered delegates an opportunity to learn more about the psychological factors which influence compliance and patient behaviour when using oral nutritional support products. The ‘Power of taste’ session was hosted by Philip Graves, Consumer behaviour expert and provided a valuable insight in some basic techniques which may help to improve patient perception of ONS and consequently improve overall compliance and experience with ONS.

Day 2 saw an (optional) early start with a breakfast For the afternoon breakout sessions, delegates could session, ‘Putting fibre back on a pedestal’, which was choose between a BDA Education Board session to hosted by Cereal Partners, Nestle Breakfast Cereals. discover the future direction of dietetic practice and During the workshop, Professor Chris Seal from the implications for dietetic education. Alternatively, Newcastle University presented the latest information the Public health and Paediatric Specialist Group on fibre and wholegrains in the diet. The 2015 were offering an update on a joint approach to the Scientific Advisory Committee on Nutrition Report The final part of the research was to computer-plan challenge of childhood obesity. In this session, Dr on Dietary Carbohydrates and Heath was central to individual diets for 26 willing subjects, with a view to Julie Lanigan RD PhD, Principle Research Associate, the session. more modest post-prandial Chair of Paediatricglycaemia.

Specialist Group and Horary The morning plenary session for Day 2 was firmly Specialist Dietitian at Great Ormond Street Hospital looking ahead for Dietetics and its potential to for Children NHS Trust discussed current research embrace technology and innovative ways of working. and thinking in early intervention for childhood Titled ‘The future: Transforming care’, the session obesity. Pip Collings, a Public Health Dietitian, included some diverse keynote presentations on provided a second presentation to share the work she remote teleswallowing assessments for dysphagia has been conducting within schools to improve patients. Here, Veronica Southern, Clinical Lead in nutrition and food.

Telesolutions at Blackpool Teaching Hospitals NHS The final plenary session of the event devoted time to Foundation, shared her experiences in setting up a a key area for the future success of Dietetics. Safe teleswallowing assessment service and the successful practice in Dietetics came under the spotlight with outcomes that this service has achieved. Judyth valuable three keynote presentations. The first Jenkins MBE, Head of Nutrition and Dietetics coming from Suzette Woodward, National Campaign Services and Julie Myers, Head of Occupational Director for Sign up to Safety. Suzette explained her Therapy Services, both at Cardiff and Vale University three things to achieve the best and safest care. Jayne Health Board, explained how an integrated Lavin, Clinical Manager for Nutrition and Dietetics at workforce could benefit patients and staff in the Aneurin Bevan University Health Board shared the current prudent healthcare climate. Both asked how success her department had had with practical the current skill mix of the MDT could be challenged supervision. Presenting staff feedback via video to ensure satisfactory patient care is delivered. during her talk, Jayne highlighted the advantages of Personalised nutrition is an area of much interest for changing department culture and the importance of the future of Dietetics. Dr Eileen Gibney, Lecturer open communication amongst staff at all levels both in Nutrition and Genetics at University College within and beyond the Dietetic department.

Dublin Institute of Food and Health gave delegates an Finally, Sue Perry, Deputy Head of Dietetics in Hull overview of current research and practical and East Yorkshire Hospitals NHS Trust, provided an application of nutrigenomics. To end the session, a insightful session on defining a safe workload. Sue’s panel discussion focused on the factors that are session focused on the results of two national shaping the future of healthcare.

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EVENTS

questionnaires which were given to dietitians (clinicians) and dietetic managers, which looked at the current workload of employees. ‘Workload’ was defined as the total amount of work a clinician manages on a daily basis. A ‘caseload’ refers to the amount of patients a clinician manages. This included daily activities and capacity, the mean number of patients seen per week and the perception of own workload safety. Perceived safety concerns for managers regarding their service were included in the management questionnaire too. It was interesting to learn about the results, as they were likely to be consistent with current trends in Dietetic workloads across the UK. The largest concerns from clinicians included being unable to see patients in a timely manner, not having sufficient time for CPD and patient documentation. Most participants reported that they were working above their contracted hours to achieve their current management of their caseload. Concerning the safety of their caseload management, 43% of clinicians did not feel safe with current workloads. The questionnaires did highlight differences in safety perspectives between clinicians and dietetic management. The session closed with a panel discussion where the framework for safe practice was considered.

The event overall highlighted the strength of current Dietetic practice and our vital contribution to the modern health and social care service. However, there are many ways to improve our position and ensure our place as ambassadors of health in the future and the BDA supports innovation and development for driving forward Dietetics. Be proud of Dietetics and join the #standingupfordietetics movement!

Andrea Raffin at www.andrearaffin.com

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