case study: ulcerative colitis

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.

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

cASe STUDy: UlceRATIve colITIS (IBD)

The impact of IBD on the nutritional status and life of an 18 year old

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

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

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

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

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.

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 Barium contrast dye is ingested by the patient followed by abdominal x-rays to follow through 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 Mesalazine (brand names include Asacol, Ipocol, Octasa, Pentasa, and Salofalk), 5-asas 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

restorative proctocolectomy with ileoanal pouch 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. 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.

Table 3 continued colectomy with ileorectal anastomosis

colectomy with ileostomy (subtotal) 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. 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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NHDmag.com October 2015 - Issue 108 49

gemma sampson rd, senior r&d dietitian, vitaflo international

Gemma has experience as a registered dietitian in a variety of clinical and industry settings, with personal interests in sports nutrition, gluten-related disorders and plant-based lifestyles. She runs the nutrition blog Dietitian without Borders.

ANcIeNT GRAINS IN THe moDeRN DIeT

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.

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

Wheat brown Rice amaranth 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

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.

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

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

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.

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 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.

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