Network Health Digest - June 2016 by NH Publishing Ltd

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

NHDmag.com June 2016: Issue 115

early years nutrition slimming groups dietetics in palliative care fermented foods IMD watch

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FROM THE EDITOR

welcome Emma Coates Editor

So here we are, half way through 2016! Go on, you can say it… where’s the time gone? Before you know it, it’ll be Christmas. Nevertheless, before we reach the warm fuzziness of the winter festive period, we have work to do.

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.

With the promise of sun and possibly some sand and sea, the huge drive to lose some of those extra pounds and get ‘beach ready’ grips the nation. Scan the covers of many of the commercial glossy magazines and they all promise the quick-and-easy summer diet plans to ‘drop a dress size’, ‘lose 7lbs in seven days’, or they reveal the diet secrets of those perfect (photo-shopped) celebrities. And it’s not only the magazines spouting this ‘dietary advice’, just using your smart phone, via social media, you can thumb your way through any diet plan you deem worthwhile in order to rock that bikini or slinky dress this summer. Thankfully, we have two articles this month which cut the wheat from the chaff when it comes to commercial slimming programmes and fad diets. In her first article for NHD, Maria Dow, Freelance Dietitian, delves into both NHS and commercial slimming programmes, outlining their characteristics and comparing outcomes. Ali Hutton, Medical Affairs Dietitian, then goes on to take a closer look at a few common fad diets which promise miraculous results in the weight management department. The June issue of NHD also has a distinct gastro feel. Freelance Dietitian Helen West shares her first article for us, which discusses probiotics, in particular, the relevance and possible benefits of fermented foods: can sauerkraut or kombucha tea really influence gut health? The third week of June is ‘Love Your Liver’ week, which is the British Liver Trust’s (BLT) national awareness campaign to highlight three simple

steps to maintain a healthy liver and reduce the risks of developing liver problems. Vanessa Hebditch from the BLT, updates us with the current liver disease facts and offers us an insight in the work of the BLT. Now, NHD is no two-horse mag, we’ve got more than just weight management and gastro to offer you. Dr Emma Derbyshire asks the question, ‘Should we make foods for little ones less sweet?’ Humans have an innate affinity to sweeter tasting food, but that shouldn’t mean that commercial food aimed at infants and young children should be sweetened, promoting the development of a sweet tooth. In her early year’s nutrition article, Emma discusses the current thinking around the early exposure to sweet tastes. Louise Robertson, Specialist IMD Dietitian, provides this month’s IMD watch article, giving us a comprehensive overview of Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) and talks us through the dietary considerations and follow-up of adults with this condition. Anne Wright RD touches on the challenging area of palliative care, defining the various stages and clarifying the nutritional goals for this patient group. We also have information on legislative changes governing gluten in foodstuffs by Helen Rose, plus our regular PENG column, reporting on their essential Dietetic Outcomes Toolkit ‘DOT’. I hope you enjoy this mid-year issue of NHD. Instead of scrolling through all of those online fad diets, I think I might start my Christmas shopping! - Emma www.NHDmag.com June 2016 - Issue 115

Contents

13 COVER STORY

Early years nutrition: avoiding a sweet tooth 6

News

Latest industry and product updates

36 IMD watch MCADD follow-up in adults

Liver disease awareness

The British Liver Trust campaign

40 Gluten in foodstuffs EU legislative changes

20 Slimming groups

45 On behalf of PENG The key to better outcomes

Pros and cons

24 Fad diets The latest trends examined 28 Palliative care A challenging role for dietitians

48 Web watch Online resources

and updates

50 Dates for your diary Upcoming events and course

33 probiotics

51 The final helping The last word from Neil Donnelly

Fermented foods

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 Dennis Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst

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

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

www.NHDmag.com June 2016 - Issue 115

ISSN 1756-9567 (Print)

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NEWS

food for thought Fresh FV intakes still disappointing A new report published by the NFU Horticulture and Potatoes Board has Dr Emma found that, since 2007, purchases of Derbyshire fruit have fallen by 14%, vegetables by 5% and PhD RNutr potatoes by a whopping 20%. As this is purchase data, taking in-home food waste (Public Health) Nutritional Insight into consideration, actual average intakes are only around three portions of fruit Ltd and vegetables per day. So, it can be seen that public health initiatives, such as the UK 5-A-Day campaign, originally launched in 2003, are not being sustained. Emma is a It is thought that the shift away from eating fresh fruit and vegetables could freelance nutritionist and former senior be down to the growing consumer trend of ‘food grazing’: eating food that academic. Her is ‘ready to go’ rather than the traditional three meals a day. This is thought interests include to impact on vegetable intakes, in particular, which are typically eaten with pregnancy and public health. an evening meal. Alongside this, only 18% of UK households now plan their www.nutritionalmeals for the week ahead, with most people doing more frequent, smaller insight.co.uk shops it seems. hello@nutritionalinsight.co.uk Unfortunately, the fruit and vegetable sector needs to keep up with this shift in consumer behaviour it seems, providing more convenient offerings. Retailers also have their role to play, with the need to offer ‘snack-ready’ fruit and veg products. These should also If you have important news or be developed with the intention of being appealing to research updates to share with children. For example, it has been proposed that children NHD, or would like to send a letter are 85% more likely to eat more fruit and vegetables when they have fun names or shapes and I have to agree. to the Editor, please email us at So, on the whole it seems that there is work to be done in info@networkhealthgroup.co.uk the fruit and vegetable sector to help it stay on trend. A degree We would love to hear from you. of innovation is needed in the way fruit and vegetables are presented, not only to make them more accessible to the generation of food grazers, cutting out peeling and slicing ideally, but also to the younger generation of children and teens.

For more information, see: NFU Horticulture and Potatoes Board (2016). Fit for the Future. Helping Consumers Eat more Fruit and Vegetables. Available at: www.nfuonline.com/nfu-online/news/nfu-reports/fit-for-the-future-april-2016/

Nutrient intakes in the ‘very’ old We are an ageing study median intakes of energy and nonpopulation, so it starch polysaccharide (NSP) were lower is great that some than requirements. In particular, NSP new studies are intakes were just 10.2 g/day, although also collecting nut- these was found to be higher in more ritional data for educated and active 85-year olds. those in the third These are important findings age. Here we have highlighting the need to collect more findings from the nutritional data for the very old. It Newcastle 85+ Study. will be interesting to see results on This publication which focuses on micronutrient intakes which will macronutrient intakes, shows that in the hopefully be published next. For more information, see: Mendonca N et al (2016). British Journal of Nutrition [Epub ahead of print].

www.NHDmag.com June 2016 - Issue 115

B12 deficiency concerns Vitamin B12, alongside folate, is essential for growth and development during the early stages of pregnancy. Now, a new meta-analysis has looked at whether this could also affect birth weight. A total of 80 articles were studied to determine worldwide prevalence of vitamin B12 deficiency and associations with birth weight. Prevalence of vitamin B12 deficiency was: • 21% - First trimester • 19% - Second trimester • 29% - Third trimester Although maternal vitamin B12 status was found to be lower amongst women with low birth weight deliveries, this was not statistically significant, though data from Indian studies mainly contributed towards this trend. Overall, these are interesting and important findings highlighting that vitamin B12 deficiency is common, even amongst non-vegetarian women. This could have broader implications for maternal and foetal health. N et al (2016). American Journal of

Confectionery (under-)reporting It makes senses that calories densely packed into children’s confectionery treats should be linked to overweight and obesity. A new meta-analysis paper has now looked into this. Data was pooled from 19 studies looking at intakes of chocolate and nonchocolate confectionery. All studies also collected data about children’s body weight, size or composition. Surprisingly, no links were found between confectionery eating and children’s body weight, size or composition. Furthermore, eating confectionery once a week was actually associated with a 13% reduced chance of children being overweight or obese. These are interesting findings indicating that, in moderation, the odd confectionery treat may not pose a threat to a child’s weight. That said, it is also possible that this is a ‘true inverse’ association where very heavy under-reporting has contributed to these findings.

print].

of Clinical Nutrition [Epub ahead of print].

For more information, see: Sukumar

Clinical Nutrition [Epub ahead of

For more information, see: Gasser CE et al (2016). American Journal

Nutrient intakes in the young Scientists from the Irish National Pre-School Nutrition Survey have analysed how fruit and vegetable intakes contribute to nutrient intakes in the very young. Data was analysed from 500 Irish children aged one to four years who completed four days of weighed food records. Overall, it was found that fruit and vegetables contributed 50% of vitamin C, 53% of carotene, 34% of dietary fibre and 42% of non-milk sugar intakes from the total diet. Intakes of fruit juice increased with age. Other recent work from the UK Gemini twin cohort study has analysed the diets of 2,336 young children aged 21 months. Parents of the children completed three-day diet diaries. It was found that energy intake, protein and most micronutrients exceeded Dietary Reference Values. However, vitamin D and iron intakes were lower, with 70 and 6% of children not achieving even the Lower Reference nutrient intakes for these, respectively. These are valuable studies highlighting what young children are eating. Clearly, there seems to be a role for vitamin D supplementation in the UK in the early years. For more information, see: O’Connor L et al (2016). British Journal of Nutrition [Epub ahead of print] and Syrad H et al (2016). British Journal of Nutrition [Epub ahead of print].

www.NHDmag.com June 2016 - Issue 115

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CONDITIONS & DISORDERS

THE SILENT KILLER: LIVER DISEASE AWARE Vanessa Hebditch Director of Communications & Policy, The British Liver Trust Before joining The British Liver Trust, Vanessa worked as a freelance communications professional for a variety of clients across the public, private and voluntary sectors. She spent 10 years at the British Diabetic Association, where she repositioned diabetes as a serious health condition. Her work culminated in managing the communications function and leading the rebrand and name change to Diabetes UK.

Liver disease is a major healthcare crisis that we must all do something about. Mortality rates have increased 400% since 1970, and it is now the third leading cause of premature death in the UK. With Love Your Liver Week taking place this month (13th to 17th June), Vanessa form the British Liver Trust gives an overview of the facts and nutritional management of the ‘Silent Killer’. Liver disease is often called the ‘Silent Killer’ as most signs and symptoms show only when damage is advanced and often irreversible. However, with earlier diagnosis and awareness of the main causes - alcohol, obesity and viral hepatitis - lives can be saved. The British Liver Trust exists to support patients and families living with liver disease and provides awardwinning information and leaflets. Crucially, we also work to improve awareness, prevention and early detection. This year, we have been successful in our application to work in partnership with the Royal College of General Practitioners (RCGP) in making liver disease a clinical priority for the next three years for the UK’s primary health care professionals and practice staff. We will be producing a range of materials to help those working in primary care to increase the number of patients who are detected with liver disease at an early stage and receive appropriate treatment. LIVER DISEASE: THE FACTS

Your liver performs over 500 vital functions, including breaking food down and turning it into energy, helping the body get rid of waste, removing harmful substances and fighting infection. Here are some of the key facts: • At least one in five of the UK population is at risk of developing

• • • •

liver disease - that’s more than 12 million of us (CMO 2013). Deaths from liver disease increased by 40% from 2001 to 2012. Liver disease will potentially be Britain’s biggest killer within a generation. Liver disease is currently the UK’s third largest cause of premature death. 25% of the population is now categorised as obese; most will have fatty liver disease and many will have inflammation and scarring that can lead to cirrhosis and liver cancer.

These shocking statistics are something we all must take heed of because liver disease will affect all of us, whether that is ourselves or someone close living with or dying from a liver condition. Some liver conditions are genetic or caused by autoimmune malfunctions, but 90% of liver disease is preventable and it is vital that we are all aware of the risk factors and main causes. These are: • drinking too much alcohol, too often • being overweight • being infected with viral hepatitis These are all things we can do something about to reduce our risk of developing liver disease. The earliest possible diagnosis and best possible care is vital for everyone affected. Andrew Langford, Chief Executive of the British Liver Trust explains: “Although the liver is remarkably resilient and can regenerate if given time to recover, by the time most people have signs and symptoms of liver damage, it is often irreversible. Three quarters of www.NHDmag.com June 2016 - Issue 115

速

CONDITIONS & disorders people already have end stage liver disease when they are first diagnosed - by this time for many it is too late.” Good nutrition supports the liver to function and helps to keep us all healthy. Eating a good, balanced diet to maintain strength and a healthy weight is essential for people with liver problems. Some liver diseases are linked to being overweight; 90% of morbidly obese individuals are thought to have fatty livers. Obesity can also speed the damage associated with other conditions such as alcohol-related liver disease and can decrease the effectiveness of treatments for hepatitis C. It is, therefore, important to maintain a healthy weight, but it is also important for those working in the diet and nutrition industries to be aware of the fact that patients who are overweight are more at risk and may need to be tested to see if they have a problems with their liver. For people who are diagnosed with advanced liver disease and are experiencing symptoms such as fluid retention in the abdomen, their weight may be affected and BMI results can be misleading. In this instance, their diet will need to be managed very carefully by a dietitian with experience of managing liver disease, as it is possible to be overweight as a result of the fluid retention, whilst also to be malnourished. The damage caused by liver disease can also affect the liver’s ability to store and release glycogen, causing fatigue. If you go for long periods of time between meals, the body will start to use its own muscle tissue, or fat, to provide energy, which can lead to malnutrition, muscle wasting and weakness. Patients with liver disease may experience symptoms such as nausea, low energy levels, fluid retention in the legs, or accumulation of fluid in the abdomen (ascites). In these cases, patients will need to follow a more specialised diet. They may also become ill, lose a lot of weight and may not feel like eating. Eating and keeping to a well-balanced diet may be difficult in these circumstances and the patient may need specific advice on how to increase calories and protein intake. These, and other problems associated with liver disease, require specialist dietary advice tailored to the individual from a registered dietitian.

IS COFFEE BENEFICIAL?

There is a growing body of evidence that suggests drinking moderate amounts of coffee can reduce your chance of developing liver disease and can also limit the rate at which liver disease progresses. The British Liver Trust is calling for more clinical research in this area. Although it appears that drinking coffee is beneficial, it is far more important to keep to a healthy weight and not drink too much alcohol. WHAT DOES IT MEAN TO LIVE WITH LIVER DISEASE?

The British Liver Trust is contacted every day by people affected by liver disease. Real people and their stories bring to life the reality of living with the condition and the devastating effect it can have on their everyday lives and their families. A wife whose husband passed away with Non-Alcoholic Steatohepatitis (NASH) told the Trust: “In late 2013, my husband was given the terrible news that he had cirrhosis of the liver. He was not a drinker and as a Greek Cypriot he ate a well-balanced good Mediterranean diet. He was given no treatment and our GP did not really understand the situation. He had not been able to eat for months, lost a lot of weight. Eventually, on Boxing Day 2013, I got him into A&E and within four hours he saw a Liver Specialist and was admitted to hospital. “Unfortunately, he did not respond to the treatments available and after suffering, but still wanting to live and managing to ‘cope’, he eventually died on 5th August 2014 from NASH. This disease needs more done to expose it. Liver disease is always associated with drinkers and, therefore, gets neglected; more should be done to tell people that children and non-drinkers also can suffer from it.” A young woman with Autoimmune hepatitis (AIH) said: “I am not going to lie, it’s not easy being giving this diagnosis and it’s not easy to tell people how you feel, as AIH is not visible. A disease that isn’t visible to people usually means it’s not that bad (in people’s heads). I have bad days, where I just want to sleep, my whole body aches and I don’t want to see anyone, but my loud and happy personality usually takes over and I quickly snap out of it and just carry on. I am slowly learning to live with AIH (and all that www.NHDmag.com June 2016 - Issue 115

CONDITIONS & disorders comes with it) and I found some great advice from the British Liver Trust.” You can read more stories from people affected on the British Liver Trust’s website: www.britishlivertrust.org.uk THE BRITISH LIVER TRUST

The British Liver Trust is a charity that strives to: • raise public liver health awareness through our Love Your Liver campaign and promote lifestyle choices that could prevent liver disease developing; • campaign on behalf of people affected by liver disease, to push for early diagnosis, better treatment, more research and to get improved liver health services recognised as a top priority; • be the first port of call for anyone seeking information about liver disease, whether this be patients and their families, GPs and healthcare professionals, politicians or the media; • provide support services for patients and families through our patient support groups, website, social media services, online support forum ‘HealthUnlocked’ and our helpline; • improve awareness, prevention and early detection. WHAT CAN YOU DO AND WHAT ADVICE CAN YOU GIVE OTHERS?

Firstly, be aware of your own liver health complete our Love Your Liver health screener (www.loveyourliver.org.uk) and read the analysis of your health risks and what to do if you are at risk of liver disease. And then share the screener with your colleagues, friends and family so that they can do the same. For those wanting to decrease their alcohol intake and take the two-three days off alcohol that we recommend, our app www.spruceapp. co.uk provides daily support and encouragement to minimise the damage that alcohol does to our health. The British Liver Trust has a range of publications covering specific areas of liver disease which are helpful. Use the Trust’s website (www.britishlivertrust.org.uk) to find out more about the liver, what liver diseases there are, the research that’s being done and what the British Liver Trust is doing to fight the ever- increasing 12

www.NHDmag.com June 2016 - Issue 115

epidemic of liver disease in the UK. Please consider how you can support the work we do by fundraising events, regular contributions etc, and by encouraging your employer to choose the British Liver Trust as its nominated charity. The third week in June is Love Your Liver week. More information on how you can support the Trust can be found at www.britishlivertrust. org.uk/support-us/.

THE LOVE YOUR LIVER CAMPAIGN ‘Love Your Liver’ is a British Liver Trust national awareness campaign that aims to raise awareness of three simple steps to maintain good liver health and reduce your risks of developing liver problems: Step 1: Keep to a healthy weight Love Your Liver by making sure you have a healthy diet, plenty of water to drink and regular exercise. Step 2: Reduce the amount of alcohol you drink As a nation, we are drinking far more than our parents did. Too much alcohol can cause serious and lasting damage. The British Liver Trust recommends having two to three days each week without drinking. It’s an easy message, but a very effective way of reducing the amount you drink, giving your liver a rest and making it easier to stick within the Government guidelines of 14 units a week. Step 3: Know and avoid the risks for viral hepatitis Blood-borne viruses such as hepatitis A, B and C can cause permanent liver damage and increase the risk of liver cancer. Avoid these viruses by never sharing personal items like toothbrushes, razors, nail scissors or tweezers, drug equipment and by practising safer sex. If you get a tattoo, make sure it is in a licensed parlour. If you think you may have been at risk in the past - even if it was a long time ago - ask your doctor for a test.

Visit our online screener to see if you are at risk: http://loveyourliver.org.uk/ love-your-liver-health-screener/

cover story

EARLY YEARS NUTRITION: AVOIDING A SWEET TOOTH Dr Emma Derbyshire Independent Consultant, Director of Nutritional Insight Ltd Emma is a Nutrition Consultant who writes regularly for academic and media publications. Emma has worked on a wide range of projects from government reports, product development, writing and research projects. Her specialist areas are maternal and early yearâ&#x20AC;&#x2122;s nutrition, public health nutrition and functional foods.

Our innate preference is for sweeter foods. Breast milk, for example, is naturally sweet. Given this, many foods manufactured for infants and toddlers are sweetened to improve acceptability. This article discusses the role that vegetables can play in counterbalancing the stealth of sweet exposures during the early years. Secondary analysis of UK National Diet and Nutrition Survey Data (years 3 and 4) is included and general recommendations made. EARLY EXPOSURES

Our innate preference for sweeter foods may stem from the fact that carbohydrates are a much needed energy source required during the early years.1 Unfortunately, vegetable intakes seem to suffer for this very reason, with their calcium content thought to play a role in their bitter taste, reducing acceptability.2 Secondary analysis of data from the UK National Diet and Nutrition Survey (years 3 and 4) shows that fruit intakes are 44, 31 and 35% higher than vegetable intakes for one-, two- and three-yearolds, respectively (Figure 1).

So, what can be done? A growing body of evidence suggests that there could be value in introducing vegetables first during weaning. In one new study, infants provided with vegetable purĂŠes at the start of weaning had a higher vegetable intake when followed up at one year of age.3 Other work has shown that there may be a sensitive window for the acceptance of tastes. This is thought to be between the ages of four and six months, indicating that this is when vegetables need to be introduced.4

Fruit and veg intakes (g/day).

Figure 1: Fruit and vegetable intakes in the early years

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Repeated exposure (offering the same food continually) is also more likely to be needed for vegetables, especially as children get older. One study recruiting 72 children aged nine to 38 months showed that it took 10 exposures before artichoke intake increased, with little ones eating

more of this than traditional veg by the end of the study.5 Other similar work with 29 preschool children aged 15 to 56 months showed that acceptance of a root vegetable purĂŠe took six to eight exposures. Interestingly, adding apple to this did not improve uptake any faster.6

% total energy from NMES

Figure 2: Average NMES in the early years

5% Energy

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early years nutrition SWEET EXPOSURES

There has been much discussion about sugar recently. Secondary analysis of National Diet and Nutrition Survey Data (years 3 and 4) has shown that intakes of non-milk extrinsic sugars (NMES) during the early years rise from 10 to 13% between the ages of one to three years (Figure 2). While NMES are not exactly ‘free sugars’, they are the closest marker we have to date. Comparing NMES intakes against present advice that the population average of free sugars should not exceed 5% of total dietary energy, from two years of age and upwards,7 it can be seen that this is exceeded by around twofold. In terms of sources of sweetness, data from that latest NDNS highlighted that the main sources of NMES were non-alcoholic drinks (27-30%) and cereals and cereal products (2529%) for children aged 10 years and under.8 Secondary analysis looking at volumes of

foods consumed during the early years shows similar trends. Soft drinks, fruit juice, yoghurt, fromage frais, dairy desserts and breakfast cereals are consumed in some of the highest amounts (Figure 3). Interestingly, the use of commercial toddler foods and drinks declines steeply from 26.9 grams per day at age one to just 5.2 grams per day at three years. The broader range of foods introduced with age may go some way to explaining why NMES intakes rise. THE WAY FORWARD

It seems that weaning advice may need to be updated, with encouragement to introduce vegetables first. In one study, mothers’ added vegetables to milk, then baby rice and then as a pureé with feedback that they liked this straightforward, step-by-step approach.9 During the early years, little ones should also be encouraged to drink water once they

Habitual intakes (g/day)

Figure 3: Sweeter options - amounts consumed during the early years

(n=171; NDNS data; years 3-4). www.NHDmag.com June 2016 - Issue 115

early years nutrition

During the early years, little ones should also be encouraged to drink water once they are weaning. Drinking water with vegetables has also been found to help dilute the bitter taste and improve their acceptability. are weaning. Again, a level of repetition and persistence may be needed before this is accepted. Drinking water with vegetables has also been found to help dilute the bitter taste and improve their acceptability.10 The temptation to introduce squash or fruit juices should be avoided if possible, with these being served as an ‘occasional treat’. The new Eatwell Guide does not apply to children under two years, due to their different nutritional needs. However, for those between the ages of two and five years, it is advised that they move on to eating the same foods as the rest of the family. However, within this guidance, it is advised that intakes of fruit juice and/or smoothies are limited to a total of 150ml per day.11 In terms of branding, the new Ending Childhood Obesity report published by the World Health Organisation recommends that regulations are developed on the marketing of complementary foods and beverages, to limit the consumption of foods and drinks high in sugar (along with fat and salt).12 This is sensible, but also needs to be extended to foods marketed at toddlers and young children.

Finally, it should be considered that, while many complementary foods are now specifying that they do not contain ‘added sugars’, they quite often contain other sources of sweetness. Examples taken from a crosssection of products include honey, grape, apple and banana juice, malted barley extract and coconut blossom nectar. This is a trend that is likely to grow: the use of alternative sources of sweetness other than sugar. CONCLUSIONS

Undoubtedly, our innate preference is for sweeter foods. However, it is important that other foods are not overlooked because of it. Unfortunately, this seems to be the case for vegetables. Manufacturers also seem to be developing products that are sweet, if not with sugar then with fruit concentrates or juices. These stand prominently on the shelves, with only a few savoury or vegetable based products available. So, while more transparent labelling of ‘free sugars’ is needed to fall in line with new guidelines, the question we also need to be asking is, “Should we not be making foods for little ones ‘less sweet’ overall?”

References: 1 Ventura AK and Mennella JA (2011). Innate and learned preferences for sweet taste during childhood. Curr Opin Clin Nutr Metab Care 14(4): 379-84 2 Tordoff MG and Sandell MA (2009). Vegetable bitterness is related to calcium content. Appetite 52(2): 498-504 3 Barends C et al (2014). Effects of starting weaning exclusively with vegetables on vegetable intake at the age of 12 and 23 months. Appetite 81: 193-9 4 Coulthard H et al (2014). Exposure to vegetable variety in infants weaned at different ages. Appetite 78: 89-94 5 Caton SJ et al (2013). Repetition counts: repeated exposure increases intake of a novel vegetable in UK preschool children compared to flavourflavour and flavour-nutrient learning. Br J Nutr 109(11): 2089-97 6 Ahern SM et al (2014). The root of the problem: increasing root vegetable intake in preschool children by repeated exposure and flavour-flavour learning. Appetite 80: 154-60 7 Scientific Advisory Committee on Nutrition (2015). Carbohydrates and Health. TSO: London 8 Bates et al (2014). National Diet and Nutrition Survey - Results from Years 1, 2, 3 and 4 (combined) of the Rolling Programme (2008/20092011/2012). PHE: London 9 Hetherington MM et al (2015). A step-by-step introduction to vegetables at the beginning of complementary feeding. The effects of early and repeated exposure. Appetite 84: 280-90 10 Cornwell TB and McAlister AR (2013). Contingent choice. Exploring the relationship between sweetened beverages and vegetable consumption. Appetite 62: 203-8 11 Public Health England (2016). The Eatwell Guide. Available at: www.gov.uk/government/publications/the-eatwell-guide 12 World Health Organisation (2016). Report of the Commission on Ending Childhood Obesity. WHO: Geneva

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WEIGHT management

COMMERCIAL SLIMMING PROGRAMMES: WHICH WAY DO I TURN? Maria Dow Freelance Dietitian

Maria is a registered dietitian with 25 years’ experience, 12 of which have been spent specifically in weight management in the primary care and academic sectors. She is currently working as a Freelance Dietitian in the Aberdeenshire area.

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

There is a plethora of advice available to someone who wishes to lose weight, ranging from commercial slimming organisations and primary care support groups to fad diets. How do we as health professionals decipher fact from fiction to best serve our patients and guide them to an evidencebased programme that best suits their needs? Nearly two thirds of the UK population are either overweight or obese. The prediction is that approximately half will be obese by 2050,1 compared to the current rate of one in four.2 In 2014, survey results from Mintel highlighted that over half the population, approximately 29 million were trying to lose weight.3 About half had tried cutting back on fatty foods, having smaller portions and/or consuming less sugar; 60% were trying to lose weight by being more active. There is clearly a myriad of routes tried by millions towards weight loss. WHAT WORKS BEST AND FOR WHOM?

Obesity is a chronic, remitting, relapsing disease which requires ongoing support. Increasing body fatness is associated with serious medical conditions with 90% of persons with Type 2 diabetes having a BMI >23kg/m2.4 There is a fivefold increase in the risk of hypertension and a doubling in the risk of coronary artery disease in persons with BMI >30kg/m2.4 The risk of osteoarthritis rises with increasing body weight, resulting in reduced mobility. Obesity related comorbidities clearly affect quality of life and may make it harder to lose weight. Weight is lost by consuming fewer calories than we use up in physical activity. The most effective programmes for optimal weight management have dietary, activity and behavioural components.5,6 Findings from a review of all UK interventions, with recent peer

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review evidence of their effectiveness in realistic settings, concluded that no single approach to weight management is effective for everyone.7 Different approaches suit different people, which concurs with several other studies.8,9,10 NICE recommendations deem the following commercial programmes of weight management to be effective at 12 and 18 months; Rosemary Conley, Slimming World and Weight Watchers.5 Published data has shown that NHS referral onto commercial programmes works.12,13 The findings of a randomised controlled trial (RCT) looking at four commercial weight loss programmes was published in 2006;10 293 volunteers with a mean age of 40, mean BMI 31.7 were randomised into one of five groups. The self-help cohort was allocated Atkins or Slim Fast in which participants adhered to the guidelines from a book or support pack respectively. These were compared to attending weekly Weight Watchers and Rosemary Conley slimming groups. Rosemary Conley slimming classes have moved to having an online presence and, as such, data pertaining to these groups have been removed from this article. The final group was a no intervention control group. Persons with Type 1 and 2 diabetes and diagnosis of coronary heart disease were excluded. Mean weight losses for completers at six months were: • Atkins - 8.5kg • Slim Fast - 6.5kg • Weight Watchers - 8.0kg • The no diet control group gained 0.9kg

This reflects the 1.0kg gain that is seen in the population if there is no conscious effort to manage weight.14 Behaviour beyond the initial six months was also looked at. It was clear there was an advantage in the commercial programmes that offered group support compared to self-help programmes. A more recent RCT compared a range of commercial and primary care led weight reduction programmes,12 in which 740 participants were randomised to one of three commercial programmes; Weight Watchers, Slimming World and Rosemary Conley, or managed via an NHS group programme, GP or pharmacy programmes. The mean age of participants was 49 years and BMI 33.6kg/m2. It was not stated as to diabetes status. The mean number of visits over the first 12 weeks in the commercial slimming groups, GP and pharmacy interventions was 12, and eight in the NHS group programme. Number of visits beyond the first three months was less clear. The mean weight loss at 12 months for completers was; -4.4kg, and -3.1kg for Weight Watchers and Slimming World respectively. This was compared to local NHS weight management support, GP and pharmacy weight management programmes which achieved -3.7kg, -1.3kg and -1.2kg at 12 months. For patients who were allowed to choose the intervention of their choice which best suited their needs, the mean weight loss at 12 months for completers was -2.9kg.14 Data from another RCT comparing a commercial weight management provider with standard care, revealed a mean weight change of -5.06kg for the commercial group at 12 months compared to a weight change of -2.25kg receiving standard care. The mean number of visits in 12 months was 36 versus 12 respectively.15 UK SLIMMING ORGANISATIONS

Weight Watchers and Slimming World (Table 1) are market leaders for commercial slimming organisations in the UK. They offer those wanting to lose weight an opportunity to be part of a group which is aimed to provide moral support with others who can spur them on. Sessions are usually held in non-NHS settings at times that suit different working patterns. Groups are open and last 60-90 minutes, with new participants welcome at any point.

The leader is trained to a set standard and has experience of managing their own weight with the programme. One-to-one support is offered briefly during weighing, which can be used to discuss personal calorie or points allowances. Additional support can be via email, magazines and/or telephone support from a trained consultant. Each programme works on an energy deficit approach through prescribed eating plans, points system or goal-setting approaches. Members are encouraged to set goals to increase their level of physical activity to achieve 30 minutes moderately intensive exercise most days of the week, ultimately increasing to 10,000 or more steps daily. There is a recognition within many slimming groups of the use of behavioural strategies, such as regular weighing, nutrition and physical activity education, social support, relapse prevention and rewards. Commercial based providers are in a good position to provide weight management support. The research shows that they have good outcomes for patients who have no mobility issues, BMI <35kg/m2, and few comorbidities, such as diabetes.7,10 Clinical judgement is needed to determine whether they are suitable for patients with higher levels of obesity and more complex needs. There is also a need for longerterm data beyond 12 months. www.NHDmag.com June 2016 - Issue 115

WEIGHT management NHS WEIGHT MANAGEMENT SERVICES

There are few peer reviewed studies on the weight change outcomes of NHS weight management programmes. The biggest to date is The Counterweight programme which is a prospective evidence-based intervention for weight management (Table 1). Healthcare staff are trained and mentored to deliver a structured programme to overweight and obese patients. In 2008, the programme was evaluated. Training and mentoring was standardised and competency-based. Mentoring was provided to healthcare staff to provide on-the-job supervision. Patients were seen either individually or via small closed groups.16 They attend six structured intervention sessions over three months, then threemonthly reviews thereafter for a year to encourage weight-loss maintenance. The sessions cover previous weight loss history, weight loss expectations, managing difficult times,

physical activity, SMART goal setting, eating behaviours and weight loss maintenance. There is an emphasis throughout the programme on behaviour change strategies. In the study, 1,906 patients were recruited to attend the programme via their GP practice. The mean BMI was 37kg/m2. A quarter of participants had a BMI >40kg/m2. Three quarters had at least one obesity-related comorbidity, with 25% having three or more. Mean weight losses at 12 months were -3.0kg and 31% of completers achieved >5% or 5.0kg weight loss at 12 months. The mean number of visits was eight. The number of visits associated with optimal weight loss was between 10 and 15.16 This programme used in the pharmacy setting in a later evaluation showed weight loss outcomes.17 There has been mixed data published relating to primary care weight management programmes. This perhaps relates to the many

Table 1: Characteristics of weight management programmes Weight Watchers www.weightwatchers.com • Open group and/or online membership. • Weekly group meetings approx. one hour held at same day and time at local community venue. • One-to-one support for new clients and during weighing. • New members given points budget which considers height, weight, gender and age. • Group talk from leader who has experience with managing their weight with the programme.

• • • •

500Kcal deficit plan discussed using points system. Recipes and menu plans given. Aims for 0.5kg-1.0kg weight loss per week. Physical activity encourages gradual increase to 10,000 steps daily. • Weekly supportive emails. • Behavioural strategies discussed in group sessions.

Slimming World www.slimmingworld.co.uk • Open group, new members can join at any time. • Weekly support in community venues. Same day and time. • Leaders are ex-members who have lost weight with the programme. • 60- to 90-minute sessions. • Individual support if needed. • Access also to website, magazines and one-to-one telephone support from a consultant.

• Recipes and menu plans. • Food optimising emphasising low energy density foods that encourage optimal satiety and create energy deficit. Personal eating plans. • Mini targets negotiated for dietary and physical activity changes. • Behavioural strategies highlighted in groups to encourage weight management.

Counterweight www.counterweight.org • Practitioners trained and mentored by registered dietitians. • Structured lifestyle programme based on everyday foods, drinks and activity. • Nine education appointments delivered either individually or via closed groups (60 to 90 minutes) over one year. • Energy deficit created using SMART goals or 500600Kcal prescribed energy deficit dietary plans.

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• Menu planning. • Behavioural strategies used to ensure long-term changes to dietary and activity habits. • Delivered in NHS settings, community settings and pharmacies. • Aim to achieve 5-10% or 5-10kg and weight loss maintenance.

Table 2: Examples of fad diets • Low carbohydrate diet

• Macrobiotic diet

• Grapefruit diet

• Blood type diet

• Detox diet

• Juicing diet

• Cabbage soup diet

• Secret diet drops

different aspects of primary care programmes, with no standard training or accreditation to the training for practitioners delivering sessions. Mentoring is a key aspect to successful and competent delivery of weight management in primary care settings.18 FAD DIETS

Half the population is trying to lose weight and £1.8 billion was spent on diet food products in 2013 (Mintell 2014).3 The offer of a quick fix, with a promise of large weight losses can be very alluring. There is little information as to the numbers following current ‘fad diets’. These diets are very restrictive and often contain unusual food choices. There is little scientific understanding of healthy nutrition within these diet plans. Focus is on energy deficit with little consideration for increased physical activity or long-term behaviour change strategies. Some fad diets recommend certain vitamins, minerals or specific supplements that encourage fat burning and weight loss. It useful to inform patients that any effective programme will have quantitative evidence of results. Many fad diets are based on personal testimonials or celebrity endorsements which would not stand up to the rigours of scientific peer review. Examples of some popular diets can be seen in Table 2. Characteristics of a Fad Diet:19 • Promise of a magic bullet and it will solve your weight loss problems. • Promise rapid weight losses of more than 2.0lbs body fat in a week. • Involves dietary manipulations to detox and cleanse the digestive system. • Recommends fat burning effects, e.g. grapefruit diet. • Avoidance of whole food groups and recommends vitamins and supplements.

• Promotes eating only one type of food, e.g. cabbage soup diet. • Recommends food for genetic type or blood groups. • Has only celebrity endorsement and no quantitative evidence. • Involves long-term reliance on vitamins, minerals or supplements. Fad diets can create unrealistic expectations of weight loss and are unsustainable. It is valuable to speak with patients about their previous dieting history and ascertain their expectations of a successful programme. We can see from previous data that irrespective of the mode of delivery of weight management programmes, successful weight management is reliant on optimal attendance.12,16,17 Meeting patient’s expectations has a bearing on continued attendance. Other factors associated with greater attendance appear to include: ages 35-44, higher baseline BMI and absence of diabetes and arthritis.16 CONCLUSION

Studies seem to concur that one size does not fit all.7,10,11 Commercial weight loss programmes effectively support overweight and obese patients to manage their weight. They are best, but not exclusively, suited to patients with BMI <35kg/ m2 and uncomplicated obesity. Patients with higher BMIs, especially above 40, seem to benefit more from programmes delivered by healthcare professionals based in primary care. Staff delivering these programmes should be trained to a high standard and mentored to ensure optimal competency. The use of fad diets continues. Health professionals need to be aware of the detrimental nature that these may have on health and also on patient expectations of successful weight management programmes. Expectations have a bearing on attendance which further influences weight management success. www.NHDmag.com June 2016 - Issue 115

WEIGHT management

POPULAR FAD DIETS Ali Hutton Registered Dietitian, Vitaflo International

Ali works as a Dietitian in Medical Affairs and Marketing at Vitaflo International and as a Freelance Dietitian at the Grosvenor Nuffield Hospital in Chester.

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

Todayâ&#x20AC;&#x2122;s high prevalence of obesity, combined with less than satisfactory results using traditional weight-control methods, has helped to foster the popularity of fad diets.1 The purpose of this article is to look a little closer at three of these diets, to enable a better understanding of them, so that we can offer our patients more informed advice should they wish to commence one. As dietitians, we are often asked for our opinion on or advice around commencing a popular or fad diet, and sometimes we find that a patient has already commenced one. With an increased access to and use of the internet and social media, new diets are reaching our patients every day, making it hard to keep up-to-date with all of them. The British Dietetic Association (BDA)2,3 and NHS Choices4 have created useful lists of the most current popular and fad diets, outlining the claims behind and the pros and cons of each. Many of these diets are endorsed by or associated with celebrities and include the Paleolithic diet, the Bulletproof diet, the Super Elixir diet, the No Sugar diet, the 5:2 diet, the Dukan diet and the South Beach diet. Here, I will be taking a closer look at three of these diets. THE PALEO DIET

One of the most controversial diets in recent times is the Palaeolithic diet, also known as the Stone Age diet, the Caveman diet, or simply the Paleo diet.5 The Paleo diet is a regime based on the supposed eating habits of our hunter-gatherer ancestors during the Paleolithic era, before the development of agriculture around 10,000 years ago.4 It is described as the diet that humans are genetically adapted to, containing only foods that can be hunted or fished 24

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for (i.e. meat and seafood) and gathered (i.e. eggs, nuts, seeds, fruit, vegetables, herbs and spices).4,6 This means that cereal grains, dairy products, refined sugar, legumes, potatoes, processed foods, alcohol and salt are excluded.2,4 Advocates of the Paleo diet claim that as a long-term healthy eating plan this diet can achieve weight-loss, improve lipid profiles5 and reduce the risk of diabetes, heart disease, cancer,4 metabolic syndrome, acne vulgaris and myopia.7 The diet has some positive aspects, such as encouraging an increase in the consumption of fruits and vegetables and a reduction in the consumption of processed foods.4 It is simple, flexible and doesnâ&#x20AC;&#x2122;t involve calorie counting. The Paleo diet has, however, been shown to be 9.3% more expensive than a diet of similar nutritional value,6 which may limit the dietâ&#x20AC;&#x2122;s use to those on a higher income. The BDA2 deems the diet to be unbalanced, time-consuming and socially-isolating, and one which could comprise a healthy relationship with food. It also warns that excluding dairy completely from the diet, without very careful substitution, could compromise bone health due to a lack of calcium. Indeed, a number of studies have shown that calcium intake is below the recommended amounts in those following the Paleo diet.6,7,8

Most studies on the Paleo diet are small, THE DUKAN DIET short, heterogeneous in design and The Dukan diet is a weight loss plan devised underpowered5 and more long- by French Doctor, Pierre Dukan. It claims to term research is needed to show achieve a weight loss of up to 2lb per week and conclusively whether or not it is as to promote long-term weight management.4 effective as some people claim. There It is a low-carbohydrate, high-protein diet are no accurate records of the diet of and consists of four phases. The attack phase our Stone Age ancestors, so the Paleo involves adhering to a strict lean protein diet for diet is largely based on an educated five days, with the aim of achieving rapid weight guess, with its health claims lacking in loss. Carbohydrate (including fruit and vegetable scientific evidence.4 Doing a quick internet search sources) is off limits, with the exception of a small will reveal a lot of conflicting advice around the amount of oat bran. The cruise, consolidation Paleo diet, with some websites supporting the and stabilisation phases of the plan involve diet9,10 and others criticising it.11,12 Taking all of the progressive reintroduction of some fruit, this into consideration, it is little wonder our vegetables and carbohydrate, and eventually patients can become misled and confused by this all foods.14 There is no limit to how much can be diet. eaten during the planâ&#x20AC;&#x2122;s four phases, provided People on the Paleo diet should be referred that there is strict adherence to the rules of the to an accredited dietitian for individualised plan. There is no time limit on the final phase, advice and to discuss potential nutritional which involves having a â&#x20AC;&#x2DC;protein-only dayâ&#x20AC;&#x2122; once inadequacies such as calcium.5 Encouraging per week and taking regular exercise.4 an increase in activity levels that mimic our Studies have demonstrated that the diet Paleolithic ancestors, rather than trying results in a reduced energy intake, which is to copy their supposed diet, has also been responsible for the lowering of body mass.15 The NHD Magazine_0516_path.ai 1 24/5/16 10:29 AM 4,13 recommended. rapid weight loss and prescriptive nature of the

CMY

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WEIGHT management

The Paleo diet is a regime based on the supposed eating habits of our hunter-gatherer ancestors . . . containing only foods that can be hunted or fished and gathered . . . diet are likely to be key motivators for people who wish to follow the Dukan diet. A number of side effects of following the Dukan diet have been reported and include bad breath, a dry mouth, tiredness, dizziness, insomnia and nausea from cutting out carbohydrate, as well as constipation from a lack of wholegrains, fruit and vegetables in the early stages.4 More worryingly, studies have warned that nephrolithiasis is a potential side effect and so, persons with a known history of this disease should not follow this diet.14,16 Concerns have also been raised about the potential progression of chronic kidney disease and the increase in cardiovascular risk when following the diet.14 One study doubted the efficacy of the Dukan diet in glucose tolerance control and weight loss,16 whilst another study revealed a lower intake of calcium, iron, potassium, vitamin C and folate, but excessive amounts of protein, phosphorus, sodium, vitamin A and vitamin D.15 In terms of safety, there is little long-term information on the health effects of high-protein diets16 such as the Dukan diet. An internet search on the Dukan diet will reveal both success stories of people who have followed it17,18 and warnings against following it.19,20 Again, given the lack of robust evidence and the myriad of confusing messages around the diet, it is easy to understand why patients are unsure of whether or not it is an appropriate weight-loss option for them. THE NO SUGAR DIET

The No Sugar diet involves exclusion of all types of sugar from the diet. The BDA3 acknowledges that cutting down on free sugars, adding less sugar to food and consuming fewer products already containing added sugar, in addition to being label aware, are positive elements of this diet. It does warn, however, that some versions of the No Sugar diet promote cutting out all sugar from the diet, which is not only almost impossible, but would mean eliminating foods 26

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like vegetables, fruit, dairy products and nuts, leading to a less than healthy diet. Fruit juice receives bad press mainly due to its high sugar content,21 but consumption of 100% orange juice has been positively associated with nutrient adequacy and diet quality, with no increased risk of overweight/obesity in children22 or adults.23 There is also convincing evidence from epidemiological and clinical studies that pure fruit juices reduce the risk of CVD,21 which demonstrates that excluding a whole food group such as fruit from the diet because of its sugar content can actually remove elements of the diet that are beneficial to health. The BDA3 advocates a whole diet approach, rather than a focus on a single food or nutrient. As with the Paleo and Dukan diets, there is a large volume of conflicting advice on the internet and social media around the No Sugar diet.24,25,26 The health benefits of reducing sugar intake have been well documented over the years, but even the Action on Sugar campaign27 is aiming for targets to reduce the amount of sugar added to food and not the complete exclusion of sugar from the diet. CONCLUSION

Given the lack of robust evidence for or against popular or fad diets and the large amount of conflicting advice on the internet and social media, it is easy to understand how patients may become misled and confused. As dietitians, rather than dismiss outright a patientâ&#x20AC;&#x2122;s desire to commence one of these diets, it may be better to discuss the lack of clinical evidence to support the diet and highlight the potential adverse effects on health that following the diet may have. If they still wish to follow the diet, then suggesting an adapted version of the diet (i.e. that doesnâ&#x20AC;&#x2122;t ban any food groups), or offering advice on how to improve the nutritional adequacy of the diet, may help to reduce some of the adverse side effects and potential risks of nutrient deficiencies that are associated with these diets.

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REFERENCES: 1. Huynh DTT et al. J Hum Nut Diet. DOI 10.111/jhn.12306 Published online 25th March 2015. 2. Data on file. Abbott Laboratories Ltd., 2007 (PaediaSure Plus & PaediaSure Plus Fibre taste testing). 3. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure Fibre taste testing). 4. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure & PaediaSure Peptide vs. Peptamen Junior Powder). *Independent, head-to-head taste testing for PaediaSure, PaediaSure Plus, PaediaSure Fibre, PaediaSure Plus Fibre and PaediaSure Peptide vs. Fortini or Frebini Energy or Peptamen Junior Powder Date of preparation: July 2015 RXANI150141

CLINICAL

THE DIETITIAN IN PALLIATIVE CARE: NO SOFT OPTION Anne Wright Registered Dietitian, AM Dietetics

Anne has extensive experience in many areas of Dietetics including clinical roles in Australia and with the NHS, in Higher Education and now is a freelance practitioner with AM Dietetics.

Dietitians who have worked in palliative care may have encountered some degree of misunderstanding from others when mentioning their role; even with suggestions that the specialty is a ‘soft option’ or akin to ‘waitressing’. Nutritional management in palliative care is, in truth, a complex and clinically challenging area. In the past, palliative care was associated with terminal care. The role of palliative care, however, not only encompasses end of life care, but also focuses on individuals with lifelong and lifelimiting conditions. WHO defines palliative care as ‘an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.’ The term ‘palliative’ is derived from the Latin ‘palliare’(to cloak); thus palliative care ‘cloaks’ disease by effective symptom management, enabling patients to live with their illness as actively as possible, promoting quality of life and sustaining patients’ families wherever they are located: home, care home, hospital or hospice.1 Palliative care focuses on preventing, treating, reducing or removing discomfort. It seeks to bring a patient personal satisfaction and improve quality of life. The goal of palliative care is to provide a balance between quality and length of life. There is an emphasis on highly integrated team care and planning with goals set also in collaboration with the patient and family members. Within palliative care, nutritional goals should reflect and be woven with those of the general goals of treatment.

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NUTRITIONAL GOALS IN PALLIATIVE CARE

The aims of nutritional support in palliative care change with disease progression. Patients must receive food and nutrition, but the emphasis is on quality of life and symptom relief rather than active nutritional therapy. The principle objectives of providing nutritional care in palliative care are to maximise food enjoyment and minimise food-related discomfort, to prevent or treat avoidable and unnecessary malnutrition and to help maintain a sense of normality within a patient’s life. When planning nutritional goals in palliative care, it is important to consider the stages through which the patient will move throughout the episode of care. During the early stages of palliative care, nutrition support is of great importance as it can provide patients with their individual energy requirements and also reduce their risk of infection, thereby improving quality of life. In the latter stages, as health deteriorates, the focus is on symptom management, physical care and psychosocial support. When moving towards the end of life, unsuitable amounts of food or fluid can negatively impact on palliative care. When the body is no longer repairing or restoring, the amount of food needed is sharply decreased. EARLY PALLIATIVE CARE

In early palliative care, nutrition should be seen as a priority. Early nutrition screening can identify problems that

affect the success of therapeutic management. Patients who are underweight or malnourished may not respond well to treatments. Finding and treating nutrition problems early may help the patient gain or maintain weight, improve the patient’s response to therapy, and reduce complications of treatment. There are many ways to improve a patient’s wellbeing and quality of life in the early stages of palliative care. The role of the dietitian in this stage of palliative care includes the following: Assessment of nutritional requirements: • Conduct screening to identify patients at risk and issues relating to medical diagnoses. • Assessment of individuals using dietetic care process. • Identify preferred likes and dislikes and lifelong food habits. • Clarify interventions that are consistent with prognosis. Symptom identification: • Identify swallowing and chewing problems, pain, constipation, early satiety, changes in taste and smell, nausea, vomiting, dry or sore mouth or throat. • Provide practical advice regarding symptoms and chewing and swallowing difficulties, in conjunction with the speech and language pathologist and other team members. Nutritional counselling and interventions: • Meal planning to meet energy and nutrient requirements in accordance with the patient’s cultural customs, preferences and abilities. • Adapt meal times to suit when a patient’s appetite is best; avoiding times when they may experience pain, nausea and fatigue as that could reduce intake. • Enable patients to eat autonomously by using adapted cutlery and/or cutting up their meals, as required. • Offer favourite foods frequently and asking family members to bring favourite foods in to encourage enjoyment of eating. • Ask patients where they would prefer to eat and encouraging eating in dining rooms

• • •

• • • •

• • •

with family and friends where possible, to enhance positive social interaction. Provide high calorie meals, drinks and snacks where appetite is poor. Consideration and recommendations of appetite stimulants. Dietary strategies that assist in the management of disease and the sideeffects caused by treatment or medications, including: a. food presentation b. food temperature c. quick easy meals d. ready prepared meal ideas e. symptom management f. modified texture diets g. frequency of meals h. suggestions for nourishing meals and snacks Answer frequently asked questions by patients and family. Provide advice regarding supplements. Provide education and support for patients and their families. Development of enteral feeding regimes when the patient is unable to meet daily fluid and nutritional requirements and this intervention is deemed appropriate by the treating medical team. Practical advice and education for staff, caregivers and family in managing enteral feeding in the community setting. Modified management of chronic conditions with special diet requirements. Cessation of therapeutic special diets may be warranted.

LATER PALLIATIVE CARE

In later stages of palliative care management, aggressive feeding may not be appropriate, especially as eating and drinking can cause discomfort and increase anxiety and stress. The aim of nutritional support should not be for weight gain or reversal of malnutrition, but should be about quality of life, comfort, symptom relief and the enjoyment of food. Strategies for supporting patients in later palliative care stages include: • reassurance and support to patient and family that reduced appetite is a normal response; www.NHDmag.com June 2016 - Issue 115

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clinical • considering treating reversible symptoms; • nourishing diet focusing on enjoyment of food and drink - this should be done without pressure on the patient to eat; • ‘little and often’ - food and drink that the patient likes and enjoys; • utilisation of the ‘Food first’ fortification approach by adding butter, cream, cheese, milk powder to enrich the nutritional value of food; • oral nutritional supplements (ONS) which may be beneficial in some patients on psychological grounds; patients should not be made to feel that they have to take these or be given false hope that these will improve nutritional status or quality of life. END OF LIFE CARE

In the last days of life, palliative care patients often experience progressive functional decline and worsening symptom burden. As the final phase of illness develops, physiological functions, such as gastric emptying, digestion, absorption and peristalsis, may decline. This can result in a reduced appetite and ability to tolerate food. Furthermore, the inability to eat or drink and body image changes can result in emotional distress for patients and caregivers. At end of life, it is common for people to stop eating. Often, patients are pushed to eat at this time to provide comfort to their families, when this pressure is likely to cause more distress for the patient than not eating at all. Treatment decisions about end of life nutrition are difficult and rarely based on evidence alone. Many considerations factor into the decisions that families and providers make about end of life feeding, including provisions in advance directives or living wills, cultural, religious and ethical beliefs; legal and financial concerns and emotions.3 The dietitian’s role is to engage in end of life discussions with the patient and family, to ensure that there are no unrealistic expectations associated with nutritional care.

ARTIFICIAL FEEDING IN PALLIATIVE CARE

Artificial nutrition is only indicated when it is in the patient’s best interests and when achievable goals can be established. The decision to commence nutritional support should take into account the associated benefits and burdens for individual patients. For patients nearing death who show interest in eating, most experts suggest hand feeding over tube feeding.3 Although hand feeding is unlikely to satisfy a patient’s nutrition and fluid needs, it addresses important basic needs that help preserve quality of life. For example, many enjoy the routine of sharing a meal with others and the flavours and textures of food. EXTENDED SCOPE IN PALLIATIVE CARE

Far from being in a specialisation which is a ‘soft option’, dietitians in palliative care find themselves in a role which reaches beyond the physical to other dimensions of care, such as social, psychological and existential. The role requires highly specialised skills in making ethical decisions about commencement and cessation of nutritional support. Dietitians in palliative care also find themselves in the role of providing psychological support to patients and families, particularly given the social significance of eating and meals and providing nutritional counselling, which is influenced by religious and cultural themes around end of life care. Dietetic consultations are often an opportunity for patients to discuss problems or issues that they are unable to raise with other healthcare professionals.2 Dietetic counselling can address patients’ fears and discomfort around food and eating, especially given the emotive and social meaning of food and its links to nurturing and even perceived survival. Dietitians in palliative care have recognised that for many of their patients, the ability to continue to eat is related to staying alive. Working with palliative patients is a great challenge and offers a range of possibilities.

References 1 Holmes S (2011). Importance of nutrition in palliative care of patients with chronic disease. Primary Health Care. 21, 6, 32-38 2 Pinto F et al. The Dietitian’s Role in Palliative Care: A Qualitative Study Exploring the Scope and Emerging Competencies for Dietitians in Palliative Care. Journal Palliative Care Medicine. 2016 3 Friedrich L. End of Life Nutrition: Is Tube Feeding the Solution? Annals of Long Term care. 2013

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Kcal Protein

400 20g Vits & Mins Fibre

50% 0 g RNI

NEW

FORTISIP 2kcal A DOSE OF SUNSHINE

*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

PUBLIC HEALTH

Helen West Freelance Dietitian

Helen has experience as both a Specialist Dietitian in the NHS and as a Freelance RD. She has personal interests in popular nutrition, the gut and the non-diet approach to health. She is also passionate about promoting evidencedbased nutrition in the media and blogs as ‘Food & Nonsense’ (www. foodand nonsense.com).

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

THE ROLE OF PROBIOTICS IN HEALTH: A CLOSER LOOK AT FERMENTED FOODS In the world of nutrition, 2016 is quickly shaping up to be the year of the gut. The link between our gut microbes and our health is an exciting and constantly evolving area of nutrition research. Probiotics and functional foods are taking front and centre stage in this year’s health trends, so here we take a closer look at the evidence behind the bacteria-containing foods that are touted as the ‘real food’ answer to optimal gut health. As diet can modulate our gut microbes and diet induced dysbiosis can affect people’s susceptibility to many diseases, gut health is an exciting area of therapy in which dietitians, have a key role to play. It has been estimated that our bowels contain around 10 trillion bacterial cells, or up to 10 times the number of human cells in our bodies.1 Unsurprisingly, although we have isolated around 400 different strains of bacteria in our gut, most remain uncategorised.2 The main focus of current research is the understanding of the functional contributions of our individual bacterial populations to health. Emerging studies have suggested that our microbes may play a role in the risk of a number of diseases, including; obesity, diabetes, inflammatory bowel diseases and cancer, to name just a few.2 Studies looking at the gut-brain axis have even linked our gut bacteria to our mood.3-6 With this in mind, one of the big questions facing nutrition professionals today is: How do we promote a healthy gut?

THE ROLE OF FERMENTED FOODS IN HEALTH

As clinicians, it’s easy to think of probiotics simply in terms of supplements, most with very little (or very shaky) clinical research for their efficacy. We know that many of these products may suffer with delivery problems. We aren’t sure of the number of bacteria they carry, or if they can survive the acidic environment of the stomach, never mind thrive in our gut and make a meaningful difference to our bowel health. However, we have been preserving foods through fermentation and eating bacteria rich foods for hundreds of years,7 so, what about the foods that are already teaming with ‘good bacteria’? Can they play a role in promoting gut health and overall well-being and should they be promoted as part of a healthy and balanced diet? Here’s a summary of the evidence for the health benefits of a few popular fermented foods. www.NHDmag.com June 2016 - Issue 115

PUBLIC HEALTH

. . . lactic acid bacteria could have a host of potential beneficial effects on health . . . Kombucha tea The popularity of Kombucha tea is on the rise. A probiotic tea which originates from Asia, Kombucha is made by adding bacteria, yeast and sugar to tea and fermenting it for at least a week.15 It’s often referred to as ‘mushroom tea’ due to the mushroom shaped bacterial culture placed in sweet tea to ferment. It contains varying levels of alcohol, depending on the fermentation practices. In mainstream health and wellness, kombucha has a serious health halo. Anecdotally, it is claimed to have a number of health benefits, including improved gut health, cancer prevention, immune system support and weight loss, to name but a few. Animal studies have shown it may be effective for moderating risk factors for heart disease, lowering Kombucha tea blood sugar levels and improving liver and kidney function.16 However, none of the health claims for kombucha are supported by clinical data in human trials, and so the health effects in people are unknown. There are also a number of documented risks for kombucha tea, including dizziness, nausea, vomiting and even hepatitis and death. Because of this, kombucha can’t be recommended therapeutically.

Wiki Commons Nagyman

Wiki Commons:Dirk Ingo Franke

Sauerkraut and kimchi Sauerkraut and kimchi are both types of fermented cabbage. Sauerkraut is of European origin and is usually fine cut and salted. Kimchi is a traditional Korean mixture of cabbage and other cruciferous vegetables, mixed with onions and spices, like ginger, red pepper and garlic. Both are usually served as a side dish to a main meal, or added to soups and stews. There are many bacteria involved in the fermentation of sauerkraut and kimchi; however, like many probiotics, the main bacteria present in these foods is lactic acid bacteria. It has been suggested that lactic acid bacteria could have a host Sauerkraut of potential beneficial effects on health, from improving gut health and supporting the immune system, to decreasing the prevalence of allergy and reducing the risk of certain cancers.8 Both kimchi and sauerkraut are nutritious low calorie foods (approx 80Kcal/100g), which contain large amounts of lactic bacteria, vitamins (A, B, C and K) as well as minerals and some functional plant compounds.9 Some popular reviews on healthy living suggest that eating sauerkraut or kimchi regularly could be beneficial to maintaining a healthy gut flora through a probiotic effect.10 In vitro and in vivo studies have found that both kimchi and sauerkraut have potential for being anticancer, antioxidant and anti-obesity functional foods.11 However, at this time, robust clinical trials Kimchi in humans to investigate the health effects, are lacking. 34

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. . . yoghurt could play a role as a functional food in weight management. Interestingly, a recent review in South Korea, where kimchi is a dietary staple, has linked their traditional dietary intake of fermented foods, with a decreased risk of atopic dermatitis.12. But so far, observational studies in humans haven’t seen any link between the intake of fermented foods (like sauerkraut and kimchi) and cancer, or overall mortality.13 Sauerkraut and kimchi have been known to cause diarrhoea in some people when they are consumed regularly. They also feature on the monoamine oxidase inhibitors (MAOIs) restricted foods list, as they are high in the amino acid tyramine and monoamine oxidase inhibitors, which are occasionally prescribed for Parkinson’s and mental health disorders such anxiety and depression. They prevent the breakdown of tyramine in the body which can cause serious health problems.14 Yoghurt Although not currently as ‘on trend’ as the other fermented foods in this article, yoghurt is probably the most widely eaten and ‘mainstream’ fermented food in Europe. It is made by fermenting milk with various strains of lactobacillus and Bifidobacterium bacteria and is seen as a staple in diets such as the Mediterranean diet, with known health benefits. Although it can be difficult to attribute a specific health effect to an individual food, many studies have found that people who eat fermented dairy foods, like yoghurt, seem to have less of a risk of cardiovascular disease and metabolic syndrome.17,18 It has also been noted that yoghurt could play a role as a functional food in weight management. Observational studies have noted a link between yoghurt and healthy body weight maintenance, including body composition. Higher yoghurt consumption has been linked with both lower body weight and weight circumference.19 However, it’s not possible to determine cause and effect and results of trials investigating yoghurt’s role in weight have been mixed, suggesting that the health effects may vary between individuals. CONCLUSION

Functional foods, such as the ones discussed in this article, could play a key role in promoting bowel health. However, at the moment there is little research into their efficacy as a wellness product or dietary treatment and more clinical research is required to determine how they work and who they may benefit.20 It’s also possible that health effects may vary between batches of these foods, as the exact nutrition composition of many of these foods is dependent on the fermentation process.21 Currently, clinical nutrition and diet guidelines make very few references to fermented foods

and when they do, they are often treated with caution.22 Probiotic foods, while mostly considered safe, may have some harmful effects and aren’t suitable for all people. However, with the exception of kombucha, including some properly made and stored fermented foods in your diet shouldn’t be risky and could be beneficial to health. More research is required to determine how these foods could be used as functional ingredients for health. www.NHDmag.com June 2016 - Issue 115

imd watch

In association with the NSPKU

MEDIUM CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY (MCADD) FOLLOW-UP IN ADULTS Louise Robertson Specialist Dietitian Inherited Metabolic Disorders University Hospitals Birmingham NHS Foundation Trust Louise has worked as Specialist Dietitian in the care of adults with Inherited Metabolic Disorders since 2008 when the adult service was set up, with particular interests in PKU diets and obesity.

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

MCADD is a rare inherited metabolic disorder of mitochondrial Î˛-oxidation of fatty acids. It is the most common fatty acid oxidation disorder with the highest incidence in Northern Europe and with a prevalence of around one in 10,000-27,000.1 It is due to a deficiency of the enzyme medium chain acyl CoA dehydrogenase which is needed for the oxidation of medium chain fatty acids (carbon chain length C6-C12).1,2 There is no chronic manifestation, but in times of catabolic stress (illness, infection, fever, fasting, poor calorie intake), the body is unable to utilise medium chain fatty acids for energy effectively, leading to a build-up of toxic metabolites which can lead to drowsiness, encephalopathy, seizures, brain, muscle and liver damage, as well as coma and even death. NEW BORN SCREENING

MCADD is now one of the inherited disorders that is screened for during new born screening (NBS) in the first week of life. Screening in England has been in place since 2009, followed by the rest of UK by 2012.1 Prior to screening, infants were commonly diagnosed when they presented with hypoketotic hypoglycaemia (from an accumulation of free fatty acids and impaired gluconeogenesis) and mortality was high.3 Metabolic decompensation was triggered by acute illness such as fever, vomiting, diarrhoea and prolonged fasting. Age at presentation ranged from a few days of life to adulthood. NBS significantly reduced clinical manifestation and death in MCADD in the Australian NBS program. Risk of death or a severe event by two years was 5% in the screened cohort vs 55% in the unscreened cohort.4

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MANIFESTATION IN ADOLESCENCE AND ADULTS

As screening for MCADD is only recent, there is a possibility of older children and adults having the MCADD gene and being unaware. Undiagnosed people are asymptomatic until an episode of increased energy demand and fasting occurs, resulting in a metabolic crisis.2 Manifestation in adolescence and adults has been reported (16 to 45 years), see Table 1 overleaf. All of the presentations were acute with multiple organ involvement and signs of decompensation which occurred due to metabolic stress. Out of the eight presentations described, half presented due to alcohol ingestion which resulted in vomiting. The rest were due to strenuous exercise without adequate nutrition, illness, surgery and pregnancy. Hypoglycaemia was only found in 50% of adult presentations,3 so normoglycaemia should not be relied on as an indicator of metabolic stability. TREATMENT: INFANTS - NEW BORN SCREENING (NBS)

Once infants have been diagnosed via NBS, then they should be seen in hospital by the specialist medical team 24 to 48 hours after the positive screening result. Advice should be given by the dietitian on safe fasting times (Table 2) and an emergency regimen given for times of illness and decreased milk/food intake.5 The emergency regimen (ER) is a glucose polymer drink given at least every three hours day and night to

Table 1: Severe first presentation of MCADD in adults3 Gender

Age of presentation

Presented with

Cause of metabolic stress

Male

30 years

Acute encephalopathy and rhabdomyolysis.

Strenuous exercise in the cold without adequate nutrition.

Female

19 years

Lethargy, disorientation and vomiting, died from cardiopulmonary arrest 24hrs later.

Vomiting following ingestion of alcohol and marijuana.

Female

16 years

Acute encephalopathy, deteriorating rapidly to coma.

Alcohol binge with starvation and vomiting.

Female

23 years

Severe vomiting, abdominal pain and encephalopathy. Died from cardiac arrest.

Heavy bout of drinking alcohol.

33 years

Lethargy, vomiting and headaches. Led to encephalopathy and cardiac arrest, which he survived.

Chronic alcoholism.

45 years

Nausea, mild hypoglycaemia leading to encephalopathy and death from respiratory arrest.

Third day post operatively following successful colon resection to remove adenocarcinoma. Five pounds weight loss prior to surgery.

Female

16 years

Found unresponsive at home, hypoglycaemic and raised ammonia, died shortly after.

One day history of nausea and vomiting following upper respiratory tract infection.

Female

29 years

Suspected acute fatty liver of pregnancy.

39 weeks gestation.

Male

Female

prevent the body using medium chain fatty acids as an energy source. The amounts and percentage of carbohydrate given depends on age (Table 3). If the ER is refused, then the child should have rapid access to their local paediatric services and avoid waiting in emergency rooms, so that there is no delay in starting an intravenous drip containing 10% glucose. TREATMENT: ADULTS

Diet in MCADD is a normal healthy diet (no need to restrict fat), regular meals with starchy carbohydrate, avoidance of medium chain triglyceride (MCT) containing products (including sip feeds and nutritional feeds containing MCT) and avoidance of prolonged fasts. Small amounts of coconut as ingredients may be tolerated, but to avoid pure coconut and coconut oil.1

Normal diets contain predominantly long chain fats (carbon chain length C16-18).These long chain fatty acids undergo Î˛-oxidation to release energy and their carbon length decreases to a medium and then short chain fatty acid length. Under normal conditions, the oxidation of medium chain fatty acids have been reported to be near normal in patients with MCADD due to over lapping substrate enzymes. This only becomes a problem when there is an increased demand for fatty acids to provide energy such as illness or fasting.1 ILLNESS

There is a high risk of decompensation during illness due to increased energy expenditure and decreased food intake/increased fasting times. During illness, www.NHDmag.com June 2016 - Issue 115

imd watch Table 2: Safe fasting times5 Age

Hours

<4 months

6 hours

4-8 months

8 hours

8-12 months

10 hours

12 months+

12 hours

Table 3: Carbohydrate % of emergency drinks5 Age

% of carbohydrate in emergency drinks

<1 year

10%

1-2 years

15%

>2 years

20%

>10 years

25%

Table 4: Carbohydrate polymers that can be used to make a 25% carbohydrate solution for Emergency regimen for >10 years8 Carbohydrate Polymer S.O.S.25 (Vitaflo) Vitajoul (Vitaflo) Maxijul Super Soluble (Nutricia) Polycal powder (Nutricia) Caloreen (Nestle)

high carbohydrate drinks must be consumed to prevent the body using medium chain fatty acids as an energy source. In adults, 200mls of a 25% carbohydrate drink should be taken every two to three hours during the day. If the illness is severe, they must continue to take the drinks throughout the night.7 The emergency drink is preferably made from a carbohydrate polymer (Table 4). In our centre, we now routinely recommend the use of pre-measured sachets of glucose polymer to make up the emergency feed as they are a more accurate method, especially in times of stress.6 A supply of the glucose polymer should be available on prescription and kept at home. If glucose polymer is unavailable, then commercial high sugar drinks can be used, but more will have to be consumed as the percentage carbohydrate content is lower (Table 5 overleaf). Care must be taken not to use sugar-free or diet drinks as the carbohydrate content will be minimal. We advise patients to call their metabolic centre for advice if they are worried or are using their emergency 38

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regimen for over 24 hours without getting better. If they cannot tolerate their emergency drinks (due to frequent vomiting or diarrhoea) then they must go immediately to hospital (via emergency department) for intravenous glucose. When presenting themselves to their local emergency department, they should bring an emergency letter from their medical team (to ensure that they are seen quickly and started on intravenous 10% glucose), a copy of their nutritional emergency regimen and supply of their emergency drinks. Patients should not continue longer than 48 hours on a carbohydrate emergency regimen as they can become nutritionally deficient.7 ALCOHOL AND DRUGS

During adolescence, a big risk factor is alcohol and drug consumption, especially binge drinking and vomiting. Alcohol consumption may lead to vomiting, hypothermia and hypoglycaemia (by inhibiting gluconeogenesis) which is dangerous, as energy generation from fatty acid oxidation is impaired in times of stress.2 Education should be given on healthy drinking guidelines: avoiding binge drinking, eating before, during and after alcohol/nights out (especially if clubbing), telling a friend about their MCADD so it is not mistaken for being drunk and to carry a wallet ID card for identification and treatment. WEIGHT MANAGEMENT

Patients should be advised to avoid crash dieting and losing weight quickly. Weight loss should be slow and steady, avoiding any long

Table 5: Carbohydrate content of commercial drinks High sugar drink

% Carbohydrate

Lucozade

17%

Coke

10%

Orange juice

10%

Ribena

10%

periods of fasting and under the care of the specialist dietitian. COMPETITIVE SPORT

Patients with MCADD can tolerate moderate intensity activity without impairing fatty acid oxidation.9 It should be advised that if the patient undertakes competitive or strenuous sport they should ensure that they have regular and sufficient food intake and food composition should be adjusted to the patientâ&#x20AC;&#x2122;s needs.2 SURGERY

If any surgery or medical procedure requires a period of fasting, then the patient must contact their metabolic team who can provide a management plan to their surgical/medical team. Often, the patient will need to be on an intravenous 10% glucose drip during the period of fasting and the procedure. The intravenous glucose must not be stopped until the patient is eating and drinking well post procedure. During anaesthetics, consideration should be given to avoiding propofol and succinyl choline due to their potential risk of precipitating myopathy.

of MCADD. There is concern that the newly screened population may enter adolescence, viewing themselves as healthy and forget about the risks of illness or alcohol consumption. Annual clinic visits are important to continue to educate them and update their emergency plan. Patients should be encouraged to keep wallet medical ID cards (with diagnosis, first line treatment and hospital contact), or a medical bracelet, to aid management and treatment in times of decompensation when they are with people who are unaware of their condition. Ensure that they have up-to-date emergency contact numbers and letters to take to hospital if unwell, to prevent long waiting periods in the emergency room. CONCLUSION

PREGNANCY

There is a growing number of screened children with MCADD who will move through into adolescence and adulthood. It is important not to medicalise these patients, but we also do not want them to forget the risk of decompensation. If they look after themselves, attend regular clinics and manage illness, then they can live a normal life. There is also the possibility that there are adolescents and adults who are undiagnosed with MCADD and they are at risk of sudden metabolic decompensation and high mortality. Fatty acid oxidation defect needs to be considered as a possibility in adults who present with unexplained sudden deterioration, particularly if precipitated by fasting or alcohol consumption.

FUTURE CHALLENGES

Useful resource British Inherited Metabolic Diseases Group website: www.bimdg.org.uk for emergency management (medical and dietetic) and MCADD guidelines for dietitians.

Morning sickness can be a problem in MCADD. Dietary advice should be given to help manage morning sickness and a low threshold for the use of anti-sickness medication. If morning sickness is severe, then the patient may need to be admitted to hospital for intravenous glucose. Planning for labour is important; patients should ensure that they have plenty of snacks and glucose polymer in their hospital bag. A medical plan is needed in case of prolonged/difficult labour or planned/ emergency caesarean section. Patients who were diagnosed after a decompensation will be well aware of the risks

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PUBLIC HEALTH

LEGISLATIVE CHANGES IN THE EU GOVERNING GLUTEN IN FOODSTUFFS Helen Rose Registered Dietitian, Interpreta Nutrition Helen is a partner in her own nutrition and regulatory affairs consultancy and has specialist knowledge of the infant, early years and dietetic food sectors. She spent 15 years working in the food industry in nutrition research and regulatory affairs roles, and scientific roles for the predecessor of the Food Standards Agency.

The current rules for foods suitable for people intolerant to gluten are harmonised in Europe, with strict conditions under which foods may be labelled as ‘gluten free’ or ‘very-low gluten’. From this summer, the rules for all gluten-free/reduced gluten foods, including specially manufactured gluten-free foods, such as those available on prescription in the UK, will be relocated within the legislative framework. Consumers will be afforded the same protection as is currently provided under the existing rules, although these foods will no longer come under the same ‘umbrella’ legislation as food for special medical purposes, which has the potential for unintended consequences for the prescription status of these foods used in the management of coeliac disease. THE CURRENT SITUATION

Commission Regulation (EC) No 41/20091 lays down harmonised rules on the composition and labelling of foods suitable for people intolerant to gluten, setting out the conditions under which foods may be labelled as ‘gluten free’ (<20mg/ kg) or ‘very low gluten’ (<100mg/kg). This legislation was largely based on the Codex standard2 that preceded it. THE FUTURE

New rules on foods for particular nutritional uses, or PARNUTS foods as they were sometimes referred to, will come into force from 20th July 2016 onwards under Regulation (EU) No 609/2013 on Food for Specific Groups (FSG Regulation).3 A three-year transition period began in July 2013 and will end in July 2016. Under the new FSG Regulation, which will replace the PARNUTS Directive,4 the Commission will lay down Directives for specific groups of foods which will include, amongst other 40

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provisions, new compositional standards for some of these foods (see Figure 1). Gluten-free/reduced gluten foods will not be included among the specific Directives under this new FSG ‘umbrella’ legislation. The FSG Regulation will repeal the current legislation on foods suitable for people intolerant to gluten and will transfer the rules for these foods to the Regulation (EU) No 1169/2011 on the provision of food information to consumers (FIC Regulation).5 The FIC Regulation already includes rules requiring the mandatory labelling of all gluten-containing ingredients, which came into force on 13th December 2014. The Commission wanted all the rules applying to gluten to be set by the same piece of legislation and established that the FIC Regulation should be the framework for the rules related to the ‘absence’ of gluten in food (i.e. gluten-free and very low gluten foods) as well as its ‘presence’ (i.e. foods that contain gluten, either intentionally or unintentionally, requiring that the cereal source of gluten is identified on the label as it represents an allergen). In terms of what these changes to the legislation should achieve, consumer protection and clarity for businesses seeking to comply with the rules should be improved. Any unintended consequences of the legislative changes for the prescription status of specially manufactured glutenfree foods are less certain.

Figure 1: Legislative provisions under the PARNUTS Directive and the FSG Regulation

PARNUTS Directive (until 19th July 2016)

FSG Regulation

FIC Regulation

(from 20th July

2016)

Infant formula and follow-on formula

Processed cereal based food and other baby food

Food for special medical purposes

Total diet replacement for weight control

Gluten-free/ reduced gluten foods

Gluten-free/ reduced gluten foods (Food for sports people - no provisions were laid down before the Directive is to be repeated)

CONSEQUENCES OF THE NEW LEGISLATION FOR FOODS THAT ARE FREE FROM OR VERY LOW IN GLUTEN

The new rules coming into force on 20th July 2016, will not change the existing rules for using the ‘gluten free’ and ‘very low gluten’ statements, which have simply been relocated within the legislative framework. The new rules draw a distinction between foods that are naturally gluten free and foods that have been specially manufactured to be gluten free, such as glutenfree foods available on prescription. This will allow statements such as ‘suitable for people intolerant to gluten’ or ‘suitable for coeliacs’ for naturally gluten-free foods and for specially manufactured foods such as gluten-free bread, the terms ‘specifically formulated for people intolerant to gluten’ or ‘specifically formulated for coeliacs’ can be used.

CONSEQUENCES OF THE NEW LEGISLATION FOR FOODS THAT CONTAIN GLUTEN

As one of the 14 identified major food allergens, rules governing the presence of gluten in foods came into force on 13th December 2014 as part of the FIC Regulation. If gluten is present in a food, the specific cereal name must be emphasised within the ingredients list (see Figure 2). It is no longer permitted to state ‘gluten’ without reference to a specific cereal in the ingredients list because gluten is not listed in the Annex II of Regulation (EU) No 1169/2011, unless it is used as an ingredient in its own right, as in the example below. In addition to gluten, wheat itself is an allergen and therefore must be labelled whenever it is an ingredient in a product, irrespective of the concentration. The consistent application of the new rules should improve consumer confidence as all www.NHDmag.com June 2016 - Issue 115

PUBLIC HEALTH Figure 2: Format for ingredient listings and allergen labelling under previous and current EU labelling rules Ingredients

Ingredients

Sugar, milk powder, rye flour, rolled oats, palm fat, gluten

Sugar, milk powder, rye flour, rolled oats, palm fat, gluten (wheat)

Allergy advice

Contains milk and gluten

For allergens, see ingredients in bold

allergens will be emphasised in the ingredients list. Under the previous rules, consumers had to look carefully at the ingredients list to find allergens that may not have been emphasised and may have looked for allergy advice statements, which were (and continue to be) optional. Allergy advice statements, where these are included on a label, must now include a phrase directing the consumer to the ingredients list (see Figure 2). The allergen labelling rules have been broadly welcomed, although one aspect that consumer groups have been less happy about is precautionary allergen labelling (PAL), such as ‘may contain…’ statements, as some consumers are under the impression that manufacturers use these to ensure that they are not held liable in the event of an allergic reaction to an undeclared allergen in their product. Food manufacturers avoid using such statements where there is no need for them, appreciating that consumers on already restrictive diets would have to further restrict their intakes of foods that ‘may contain’ specific allergens. Typically, food manufacturers risk-assess their processes before deciding whether such statements are required. Where there is a risk of cross-contamination, it continues to be advisable to use PAL in ensuring that consumers are well informed. The use of such statements is voluntary, but must not mislead. Alternatively, the manufacturer may include a claim ‘no gluten-containing ingredients’ rather than PAL. If the level of non-intentional gluten is less than 20mg/kg, it is not necessary to include PAL. The rules also extend to ‘loose’ foods (foods sold that are not pre-packaged and food that is packaged on site for immediate consumption, such as in eating-out establishments), and require that information on allergens must be provided to consumers in a clearly obvious place. The rules extend to eating-out establishments for the first time, as under the previous rules only 42

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pre-packaged foods were covered. In eating-out establishments, if allergen information is not provided upfront (such as on a menu, chalkboard or in an information pack), outlets must signpost to where it could be obtained, either in written or oral formats. These new rules have brought about a seismic shift in the food industry and eatingout establishments. The Food Standards Agency regularly issues Allergy Alerts publicising recalls of products that contain allergens that manufacturers have failed to declare on the label. The company must recall all affected batches and contact its retail customers to tell them about the recall. The company must also issue point-of-sale notices to be displayed in stores that have sold the affected product. These cases usually arise because the presence of the allergen has been overlooked (for example, if it’s contained within one of the constituent ingredients used in the manufacture of the product) rather than because the product has been accidentally contaminated with the allergen during manufacture. For eating-out establishments, at the very least staff now need to be made aware of the procedures and policies of the business when it comes to handling all requests for allergen information and they need to decide how best to communicate information about the presence of allergens in their products. POSSIBLE IMPLICATIONS FOR THE PRESCRIPTION STATUS OF SPECIALLY MANUFACTURED GLUTEN-FREE FOODS

It should be considered how the repositioning of gluten-free foods within the EU legislative framework might affect the prescription status of these foods, given that specially manufactured gluten-free foods will not fall under the FSG Regulation. The changes to the legislation described here should have no direct affect. It has always been the case that specially manufactured

gluten-free foods cannot make the claim that their products are ‘suitable for the dietary management of coeliac disease’ as the descriptor ‘for the dietary management of...’ is only permitted for foods for special medical purposes (FSMP). Gluten-free foods are not classed as FSMP under existing legislation, but rather as foods for particular nutritional uses (see Figure 1). In terms of reimbursability, EU member states have varying rules for these products. In the UK, the Advisory Committee on Borderline Substances considers the suitability of specially manufactured gluten-free foods for prescription at NHS expense, in line with UK guidelines that recommend only staple foods should be prescribed.6 However, over recent years, specially manufactured gluten-free products have become a common sight in supermarkets, in some cases with a relatively large dedicated shelf space reflecting the popularity of self-prescribed gluten-free diets for gastrointestinal symptoms, e.g. for non-coeliac gluten sensitivity.7 Both staple and ‘luxury’ products are now more affordable and accessible for those with coeliac disease as well as for those who choose

such a diet for other reasons. Some Clinical Commissioning Groups have suggested that consideration should be given to gluten-free diets being self-funded by patients as a way of reducing costs to the NHS. Such a move would undoubtedly affect dietary compliance, in particular among those patients on low incomes. It is widely recognised that the costs of treating the long-term health complications that arise from poor dietary compliance are likely to be far greater than the prescribing costs. In its most recent policy statement,8 the BDA stated that the provision of staple foods on prescription plays an essential role in supporting people with this condition to adhere to a life-long strict gluten-free diet. Although the legislative changes described in this article will not directly affect the prescription status of gluten-free foods, given the pressure on healthcare providers to reduce costs and the increased availability and affordability of gluten-free foods, the repositioning of glutenfree foods may undermine the importance of their continued availability on prescription for the effective management of coeliac disease.

References 1 Commission Regulation (EC) No 41/2009 of 20 January 2009 concerning the composition and labelling of foodstuffs suitable for people intolerant to gluten. Official Journal of the European Union L 16/3, 21.1.2009 2 Codex Standard for Foods for Special Dietary Use for Persons Intolerant to Gluten. CODEX STAN 118 - 1979. Adopted in 1979; amended 1983; revised 2008 3 Regulation (EU) No 609/2013 of the European Parliament and of the Council of 12 June 2013 on food intended for infants and young children, food for special medical purposes and total diet replacement for weight control and repealing Council Directive 92/52/EEC, Commission Directives 96/8/EC, 1999/21/EC, 2006/125/EC and 2006/141/EC, Directive 2009/39/EC of the European Parliament and of the Council and Commission Regulations (EC) No 41/2009 and (EC) No 953/2009. Official Journal of the European Union L 181/35, 29.6.2013 4 Directive 2009/39/EC of the European Parliament and of the Council of 6 May 2009 on foodstuffs intended for particular nutritional uses (recast). Official Journal of the European Union L 124/21, 20.5.2009 5 Regulation (EU) No 1169/2011 of the European Parliament and of The Council of 25 October 2011 on the provision of food information to consumers, amending Regulations (EC) No 1924/2006 and (EC) No 1925/2006 of the European Parliament and of the Council, and repealing Commission Directive 87/250/EEC, Council Directive 90/496/EEC, Commission Directive 1999/10/EC, Directive 2000/13/EC of the European Parliament and of the Council, Commission Directives 2002/67/EC and 2008/5/EC and Commission Regulation (EC) No 608/2004. Official Journal of the European Union L 304/18, 22.11.2011 6 Coeliac UK, BDA, PCSG, BSPGHAN (2011). Gluten-free foods: a revised prescribing guide 2011. Accessed on 18 March 2016 at: www.coeliac.org. uk/document-library/378-gluten-free-foods-a-revised-prescribing-guide/?return=/gluten-free-diet-and-lifestyle/pre 7 Lebwohl B, Ludvigsson JF, Green PHR. Coeliac disease and non-coeliac gluten sensitivity. BMJ. 2015; 351:4347 8 BDA Policy Statement. Gluten-Free Food on Prescription. Published September 2015. Accessed on 18 March 2016 at: www.bda.uk.com/ improvinghealth/healthprofessionals/policy_statement_gluten_free_food_on_prescription

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SHARING OUR EXPERTISE IS KEY TO BETTER OUTCOMES Anne Holdoway Consultant Dietitian

Sean White Home Enteral Feed Dietitian, Sheffield Teaching Hospitals NHS Foundation Trust and HEF Clinical Lead, PENG

Anne is a Freelance Consultant Dietitian and Chair of the Parenteral and Enteral Nutrition Group (PENG) of the British Dietetic Association. She is also Council Member of BAPEN

Sean has been a Home Enteral Feed Dietitian in Sheffield since 2004. His interests include decision making when starting enteral feeding, outcome measurement, end-of-life care and all things HEF.

In this month’s PENG column, Anne Holdoway and Sean White share news on the launch of the PENG Dietetic Outcomes Toolkit ‘DOT’ which aims to provide dietitians with a variety of approaches for collecting and reporting on outcomes in practice, with a particular focus on those relevant to nutrition support (oral, enteral and parenteral). Measuring outcomes and sharing of data ultimately demonstrates the value of our dietetic service to commissioners of services, as well as to the wider health community. Information regarding healthcare outcomes is now playing a pivotal role in medical decision-making and, as such, the measuring of dietetic outcomes and interpreting and sharing of key information is essential to ensure that others are aware of the value of the service that we are providing. Many of our colleagues across the multidisciplinary team are using outcome tools to great effect to demonstrate their impact, or justify the need for further resource, whether it be an extension of a service or the employment of more staff. In the dietetic arena, the field of outcomes assessment has not yet fully matured and yet, now more than ever, we need to ensure that Commissioners, our healthcare professional colleagues and patients are made aware of the added value we offer. Although measuring dietetic outcomes was the central theme at the BDA Conference five years ago, adoption and reporting has generally been slow to get off the ground. In response, the PENG committee and Clinical Leads agreed that one of our specialist group aims would include addressing the need to

encourage the collecting and reporting of outcomes in nutrition support. Initially, we surveyed our membership and found that many (51%) were collecting data in some form. However, many were unsure what data to collect, how to collect it, as well as experiencing issues relating to the time required and resources to collect data and report on it. The PENG outcomes project picked up pace in 2015, with the formation of an outcomes working group drawing on the expertise of PENG members with considerable clinical experience. The remit of the working group was to consider the potential of developing a tool, or resource, to assist members and dietitians working in the field of nutrition support in measuring outcomes. Following on from the membership survey and formation of the working group, we asked PENG members to share examples of outcome tools that they were using or intended to use. This scoping exercise highlighted that a large variety of tools were already in existence. Examples of tools were collated and the working group came together to review the range of outcome tools that members had www.NHDmag.com June 2016 - Issue 115

on behalf of peng

. . . we want to utilise outcome data collectively to strengthen the evidence-base for interventions and dietetic practice, enhance patient care and demonstrate the ‘added-value’ that the profession provides across the breadth of nutrition support. submitted. Structured, productive discussions amongst all the working group members both virtually and face to face, concluded that a ‘one size fits all’ solution was not what we needed, as clinical areas clearly warranted a variety of approaches. For the next phase of the project, the working group agreed that the best way forward was to evaluate existing tools, including practical application minimising the risk of reinventing the wheel and maximising output and efficiency. The results of the evaluation subsequently underpinned the development of the PENG Dietetic Outcomes Toolkit (DOT) incorporating viable tools that were considered of relevance to PENG members and dietitians working in nutrition support. The toolkit was launched in March this year at BDA Live and aims to provide dietitians with a range of approaches for addressing the challenge of measuring outcomes in nutritional care, with a particular focus on those outcomes relevant to nutrition support. The intention is that individual dietitians and departments can utilise tools from the toolkit according to time available and level of outcome data required. Ultimately, within PENG, we want to utilise outcome data collectively to strengthen the evidence-base for interventions and dietetic practice, enhance patient care and demonstrate the ‘added-value’ that the profession provides across the breadth of nutrition support. Our vision was to provide a practical toolkit to collectively capture the tools available and develop new tools to help dietitians embed outcome data collection in their practice and to facilitate the reporting of outcomes in a meaningful way, not only to us as professionals, but also for our end users and those who commission our services. We hope that this initial toolkit fulfils this need, 46

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but equally acknowledge the refinement of the toolkit will be necessary as dietitians put it into practice. The toolkit contains examples of the different tools currently available and can be used by dietitians in a variety of conditions. It incorporates case studies to illustrate, at a practical level, how each tool can be used. Use of a particular tool will depend on the patient diagnosis and the agreed goals for intervention. To allow for the cross-fertilisation of ideas, tools that are not specific to nutrition support have also been included. At the launch at this year’s BDA Live event in London, PENG had the honour of running a symposium ‘Capturing measurable outcomes in nutrition support’. The high level of attendance and interest in the session proved that outcome measurement is a key priority for many dietitians. We were lucky enough to hear inspirational talks from colleagues who had successfully implemented outcomes projects, including Bruno Mafrici, Lead Renal Dietitian/ Team Leader at Nottingham University Hospitals NHS Trust who outlined a dieteticled outcome project in dialysis; Carol Weir, Clinical and Operations Director, MoreLife and Consultant PHE Whole Systems Programme at Leeds Beckett University and Iona Taylor, Community Dietitian at Leeds Community Healthcare NHS Trust who talked about their experiences in developing and implementing therapy outcome measures (TOMs) in practice. Marianne Williams, Specialist Community Gastroenterology Dietitian at Somerset Partnership NHS Trust also shared her experiences in using simple dietetic outcome data to help secure funding. The PENG toolkit outlines a number of tools and case studies which we hope will assist dietitians in developing their own outcomes assessments. We are very grateful to

all the PENG members and NHS Trusts who helped in the development of this toolkit and hope that the toolkit will encourage dietitians across the country to share further tools. We also welcome feedback on the adoption of the toolkit and how you have used components of the toolkit in practice. By sharing experience and feedback, this will assist colleagues across the UK in demonstrating the added value that dietetics can bring to patient care. If you have any materials you would be happy to share, please email peng@bda.uk.com.

The PENG Dietetic Outcomes Toolkit (DOT) includes: • a list of nutrition support measures and relevant outcome tools that can be used • a list of potential barriers to achieving outcomes, to assist in identifying or explaining why goals/outcomes are not met, or only partially achieved • examples of tools to use in practice including: o Patient Reported Experience Measures (PREMs) o Patient Reported Outcome Measures (PROMs) o Therapy Outcome Measures (TOMs) o Goal Attainment Scale (GAS) • case histories relating to some of the tools including information on reporting • examples of assessment forms • reports generated from data collected

A free downloadable copy of the PENG Outcomes Toolkit can be found on the publications and resources section of the PENG website: www.peng.org.uk/publications-resources/dietetic-outcomes-toolkit.php

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online resources

web watch Useful information, research and updates. Visit www.NHDmag.com for full listings.

The Hospital Food Standards Panel’s report on standards for food and drink in NHS hospitals, published at the end of April 2016, looks at the quality and nutritional value of the food that is served and eaten within our hospitals. It acknowledges that inpatient nutritional care will be based on the food available within the hospital and good nutrition can help to reduce complications and aid recovery. The report also considers the impact of over nutrition for patients and NHS staff. The report aims to provide affordable and sustainable guidelines and highlights five key standards that make the biggest

Department of Health update staff: www.gov.uk/government/ difference to patients, staff and publications/healthier-andvisitors: more-sustainable-catering-a1. The 10 key characteristics of toolkit-for-serving-food-to-adults good nutritional care from the 5. Government Buying Standards Nutrition Alliance: www.bapen. for Food and Catering Services org.uk/pdfs/coe_leaflet.pdf (Department of Environment, 2. Nutrition and Hydration Food and Rural Affairs): www. digest (BDA): www.bda.uk.com/ gov.uk/government/collections/ publications/professional/ sustainable-procurementNutritionHydrationDigest.pdf the-government-buying3. Validated nutritional screening standards-gbs tool such as the Malnutrition The full report can be found Universal Screening Tool (MUST) at www.gov.uk/government/ from BAPEN: www.bapen.org. publications/establishing-fooduk/pdfs/must/must_full.pdf standards-for-nhs-hospitals 4. Healthier and More alongside the Hospital Food Sustainable Catering - Nutrition Standards Panel summary cost Principles (Public Health benefit analysis and Toolkit. England) for use by catering

NHS Choices: Stroke resources - Act FAST This resource offers key facts about stoke and what to do if you think someone is having a stroke. It also gives guidance for stroke prevention for patients: www.nhs. uk/actfast/pages/stroke.aspx

health and social care, and includes recommendations on Alzheimer’s disease. It aims to promote accurate diagnosis and the most effective interventions, and to improve the organisation of services. www.nice.org.uk/ guidance/cg42

Dementia: supporting people with dementia and their carers in health and social care

Couch to 5K campaign Encouraging increased activity levels is a key part of weight management and healthy living advice. Couch to 5K is a running plan, which has been designed to support complete novices to take up running. Josh Clark developed the plan for his 50something mum get off the couch and start running. The plan

NICE guidelines [CG42]

Updated in May 2016, this guideline it a valuable document for anyone working with this patient group. It covers preventing, diagnosing, assessing and managing dementia in

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involves three runs per week, with a day of rest in between, with a different schedule for each of the nine weeks. The campaign ties in with PHE’s One You campaign and promotes the wealth of benefits which running provides. www.nhs. uk/Livewell/c25k/Pages/getrunning-with-couch-to-5k.aspx

Stiffening of the arteries detected in young people - study A study led by King’s College, London and the University of Glasgow has found that young adults experience stiffening of the arteries in their early 20s. This is an important indicator

of long-term risks of heart and blood vessel disease, stroke and dementia. The study included 666 people aged 21-23 years of age, who were previously included in the Determinants of Adolescent, now young Adult, Social wellbeing and Health (DASH) study. The participant’s aortic stiffness, blood pressure and body size were recorded. They also completed a questionnaire on social factors such as health behaviours and social economic background. The results of the study showed that arterial stiffness increased with raised blood pressure, larger waist/ height ratio, lack of physical activity and reported racism. Up to half of the young adult participants reported some racism. A greater proportion in the ethnic minority groups than their White peers reported such incidents. However, arterial stiffness was lower among groups such as Black Caribbeans or Black Africans, compared to their White British peers, despite a greater exposure to risk from childhood, e.g. racism, overweight/obesity and deprivation. In addition, even at lower blood pressures, some participants showed greater arterial stiffening than others. Sedentary behaviour dominated the lifestyles of both men and women, with 70% of their waking hours being sedentary. However, even a small amount of moderate to vigorous activity (approx 36 minutes a day) was associated with lower arterial stiffness. There were some limitations to the study in that it was a small cohort and physical activity was not measured in detail for the baseline survey. Nevertheless,

the study has showed that early detection of arterial stiffening, together with a larger waist size, highlights the probable importance of physical activity in maintaining a healthy body weight and circulation. In addition, the effect of racism on arterial stiffening is an important factor to investigate further in order to understand the mechanism behind it, which may be linked to stress hormones. Information sources: 1. Full details of the DASH study can be found at http://dash. sphsu.mrc.ac.uk/ 2. ‘Ethnic Differences in and Childhood Influences on Early Adult Pulse Wave Velocity’ by Cruickshank et al published online in the journal Hypertension. DOI: 10.1161/ HYPERTENSIONAHA.115.07079 3. For a further review of this study visit - www.kcl. ac.uk/newsevents/news/ newsrecords/2016/04%20April/ Stiffening-of-arteries-detected-inyoung-adults.aspx Cochrane review update diabetes self-management interventions ‘Self-management interventions for Type 2 diabetes in adult people with severe mental illness’ published online at the end of April, aimed to assess the effects of diabetes selfmanagement interventions for these groups. Only one study was identified, which included 64 adult participants with Type 2 diabetes and schizophrenia or schizoaffective disorder. On average, the participants had been living with Type 2 diabetes for nine years, with their psychiatric diagnosis since the age of 28 and

the average age of the participants was 54. Throughout the study, the participants were provided with their usual care, in addition to information leaflets with a 24-week education programme delivered once a week for 90 minutes (Diabetes Awareness and Rehabilitation Training). The programme provided basic diabetes education and information about nutrition and exercise. The participants were monitored for six months after the programme was completed. Small improvements were recorded in body mass index after the intervention and improved weight management post intervention. The participants demonstrated improved diabetes knowledge and self-efficacy immediately after the intervention, and knowledge continued to be improved at six months post intervention. There was no substantial effect on glycosylated haemoglobin A1c (HbA1c) at six or 12 months of follow-up. The review recommended that more research must be conducted to establish the efficacy of Type 2 self-management interventions for people with severe mental illness. It also recommends that future research investigates the active ingredients in these interventions and the patient groups who will benefit most from them. For more information see: ‘Selfmanagement interventions for Type 2 diabetes in adult people with severe mental illness’ Hayley McBain , Kathleen Mulligan , Mark Haddad , Chris Flood , Julia Jones and Alan Simpson. http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD011361/ abstract

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dates for your diary

events and courses University of Nottingham School of Biosciences

Modules for Dietitians and other Healthcare Professionals â&#x20AC;˘ Public Health Nutrition Policy (D24PHP) 24th & 25th November & 26th January 2017

â&#x20AC;˘ Diabetes 1 (D24D01) 12th & 13th Jan 2017, 15th, 16th & 17th March 2017 â&#x20AC;˘ Understanding Behaviour Change (D24UCB) 9th & 10th February & 23rd March 2017

For further details, please contact Lisa Fox via e-mail on lisa.fox@nottingham.ac.uk or check out the University website at www.nottingham. ac.uk/biosciences> and click on â&#x20AC;&#x2DC;Study with usâ&#x20AC;&#x2122; and then â&#x20AC;&#x2DC;short coursesâ&#x20AC;&#x2122; which will take you to â&#x20AC;&#x2DC;for practising dietitiansâ&#x20AC;&#x2122;.

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For more information visit www.mfclinics.com/ keto-college/

Dietitianâ&#x20AC;&#x2122;s Week 6th-10th June www.bda.uk.com Love your Liver Awareness Week 13th-17th June www.loveyourliver.org.uk/ International Scientific Conference on Probiotics and Prebiotics 21st-23rd June Budapest, Hungary www.probiotic-conference.net. Research methods and critical appraisal courses 24th June Royal Society of Medicine 1 Wimpole Street, London W1G 0AE www.rsm.ac.uk/events/rpg10 Gastrostomy Study Day 30th June Holiday Inn London Regents Park www.vygon.co.uk/training/studydays

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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.

Now don’t take this the wrong way but this ‘Helping’ may seem a little disjointed. That’s not to say that I haven’t prepared it in time, it’s just that since the last issue of NHD, I’ve been lucky enough to go on two holidays, one to St Ives in Cornwall with my wife for a week and the other to Munich (München) for three days with a Veterans’ Football Team. Yes, I know, but it’s out of term time and someone has to take advantage of it! Having returned in the early hours of this morning, I am now addressing whether to discuss the changing culinary habits of the herring gull (commonly referred to as the seagull), the vegetable-free meals of our German hosts, or maybe some of the topics in the popular press that I read at leisure. Let’s take the gull first. Well, suffice it to say, they have become very brave in their contact with humans. Walking along the seafront in this lovely Cornish resort, eating your fish and chips, we had to be on our guard and whilst walking along the coastal path later to walk off the calories, the gulls were just as tenacious. Locals had advised us against looking at the view and warned us to stay close to the promenade. They weren’t wrong on both counts! I’ll be looking it up further when I’ve attended to other domestic matters, but food originally intended for human consumption would appear to be the main item in the gull’s diet. How has this changed I wonder and are they getting bigger? This brings me on nicely to the best spare ribs I have ever had. Now, when

you are faced with serving 26 hungry footballers (well, actually 11 hungry footballers and their supporters), I guess you have to provide good portions and this was the case. I do remember though, that when I visited the beautiful city of München previously, vegetables seemed to be somewhat in short supply. There were plenty of dumplings this time, but anything more coloured than French fries was a ‘non-starter’. Yes, I know I generalise, but I am of course only speaking from my own personal holiday experiences. So, my reader, I give you the food choices of Jonathan Livingston Seagull and the München traveller and wonder as we go forward, will our respective species gravitate even more towards ‘spuds you like’. Topics in the press? Well, only the very sad picture of Lily Collins, daughter of Phil Collins, following her dramatic weight loss for the film To The Bone in which she plays an anorexic. Maybe she should consider a holiday to Germany!

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From birth to discharge and beyond, the ESPGHAN-Compliant1 Nutriprem range has been designed to aid the development of preterm babies.

So, for a range of products that support feeding with breastmilk and contain ingredients that help preterm 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.

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E XTRA

Additional articles for subscribers only

NHDmag.com June 2016: Issue 115

IBS: THE LOW FODMAP DIET student zone

NUTRITION AND HYDRATION IN DEMENTIA: THE DMAT CARE PLAN By Lee Martin, RD

NHd-extra: COMMUNITY

Innovation in the nutritional care of dementia Lee Martin Registered Dietitian R&M Dietetics Ltd Lee Martin MSc RD is the founder of The DMAT and has a special interest in the mealtime environment in dementia. For correspondence please email info@thedmat.com.

Mealtime eating difficulties are a major contributor to malnutrition in people living with dementia, as well as a constant stress to those caring for them. This article will explain the innovative approach taken which led to the development of software to help carers identify, find solutions and create a care plan to overcome mealtime eating difficulties. Initial exposure to people living with dementia came from providing a dietetic service to a 99-bed registered dementia care home in 2011 where >90% of the residents had a form of dementia or cognitive impairment. The dietetic department would receive many referrals for malnutrition which often stated that residents were refusing to eat lunch, the main meal of the day. Very quickly, the hardest part of the dietetic role became getting people living with dementia to eat.

The loss of independence in self-feeding associated with mealtime eating difficulties can lead to weight loss, malnutrition and a poorer quality of life. When providing a dietetic assessment, all the conventional and recommended evidence-based practice approaches to improve nutritional intake were implemented. Often, these approaches would not work successfully and the person living with dementia would continue to lose weight. This led to trying a completely different approach. Mealtime observations were commenced on a particularly problematic floor in the care home to see if anything was being missed in the usual assessment approach. More was learnt in that onehour mealtime observation than in the

previous six months of discussing and planning interventions. Many mealtime eating difficulties were observed which prevented those living with dementia from consuming enough food. Eating difficulties at mealtimes have also been termed as ‘feeding difficulties’ and ‘aversive feeding behaviours’. Whatever the terms used, they describe the decline in eating abilities and behaviour associated with mealtimes in people living with dementia.1 The loss of independence in self-feeding associated with mealtime eating difficulties can lead to weight loss, malnutrition and a poorer quality of life. Problems with eating and feeding can often become a stressful time for both the carer and person with dementia.2 The difficulties observed made mealtimes a highly complex caring task. For example, some residents would struggle getting food off the plate and into their mouths, others would have difficulty chewing or swallowing and for some it seemed that they did not even recognise it was a mealtime. Those with more advanced dementia would refuse to eat or show signs of aggression. It seemed obvious that until these mealtime difficulties were resolved, dietetic advice would not be as effective as it should be. RECORDING MEALTIME EATING DIFFICULTIES

It was necessary to find a way to record these mealtime observations and, www.NHDmag.com May 2016 - Issue 114

NHd-extra: COMMUNITY Figure 1: How to use The DMAT

importantly, also have suggestions of effective interventions to overcome them. A quick look at available research showed that there was limited information available for recording mealtime eating difficulties.3 The tool that had undergone the most rigorous testing for validity and reliability only highlighted a few of the observations witnessed and provided no suggested interventions,4 plus it was difficult to find any records of it being used in clinical practice. This prompted the creation of a more practical tool to record observations and, in addition, suggest interventions to overcome the observed eating difficulties. Initially, the tool was based on the Caroline Walker Trust practical guidelines Eating Well: Supporting Older People and Older People with Dementia (pages 25-27)5 and used elements from the Edinburgh Feeding Evaluation in Dementia Scale4 to provide a simple way of measuring the frequency of the identified eating difficulties. The tool was named the Dementia Mealtime Assessment Tool (DMAT) and with the help of a dietetic student, the DMAT was used to observe and record eating difficulties in a sample of dementia residents. The DMAT was simple to use and helped identify an individualised treatment plan to target interventions on overcoming the eating difficulties. The DMAT was useful in clinical practice and its use was continued; however, it was felt that further advancement was 54

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warranted as it provided a simple solution to a complex problem and feedback from the care home was positive. DMAT INITIAL MEASUREMENT FORM

Starting an MSc in Clinical Research (MRES) at University of Hertfordshire six months later, provided the opportunity to explore the literature on dementia and eating difficulties. Available tools for measuring mealtime eating difficulties were researched and elements from each tool aided in designing the DMAT â&#x20AC;&#x2DC;Initial Measurement Formâ&#x20AC;&#x2122;3,4,6,7 Most of the research was completed in long-term care settings, although the findings could be transferrable to home care and the acute setting. INTERVENTIONS FOR EATING DIFFICULTIES

The literature was researched for effective interventions for the many different types of eating difficulties, including how manipulation of the environment and social interactions at mealtimes could aid in the improvement of eating difficulties and nutritional intake. Research in this area has been neglected, with much of the research completed over a decade ago. Recently, there has been a resurgence of interest in the topic with literature or systematic reviews and guidelines published.8-14 Guidelines however are limited in their recommendations, with many potential interventions that could help

improve eating difficulties not mentioned, despite the authors suggesting assessment of eating difficulties.13 Reading and critiquing all the different interventions made one thing completely clear: one intervention alone is not going to work. Mealtimes are complex and there is a need for multi-component interventions to address this, while ensuring individualisation of the care plan. When translating the evidence into practical interventions, this was kept in mind. DMAT PILOT PROJECTS

The DMAT has been piloted by several NHS trusts and private organisations during its development. Feedback from these experiences highlighted that the DMAT needs to become more accessible with an emphasis placed on providing interventions that are simple to initiate.

THE DMAT ONLINE SYSTEM

With the help of a software developer, the DMAT was transformed from a paper-based resource into web-based software compatible across multiple devices. The DMAT aims to help carers identify, find solutions and create a care plan for overcoming mealtime eating difficulties in dementia. The DMAT software works in three simple steps (see Figure 1). Step 1. The figure provides an overview of how to use the DMAT. First you create an account and log into the system.17 Once logged on, you can download instructions and the Initial Measurement Form in paper format to use during mealtimes if required. Based on the research literature and feedback from pilot projects, the Measurement Form helps identify 37 common eating difficulties and is split into four sections, an example of which is shown in Table 1.

Table 1: Example of common mealtime eating difficulties taken from The DMAT Initial Measurement Form Section 1 Ability to self-feed (10 items)

Not seen

Seen once

Seen repeatedly

Not seen

Seen once

Seen repeatedly

Not seen

Seen once

Seen repeatedly

Not seen

Seen once

Seen repeatedly

Difficulty identifying food from plate Falls asleep or is asleep during mealtime Incorrectly uses cutlery (spoon, fork or knife) Section 2 Preferences with food (7 items) Prefers sweet food or eats dessert/sweets first Eats very small amounts of food (or drink) Eats other peopleâ&#x20AC;&#x2122;s food (or drink) Section 3 Resistive or disruptive behaviour (12 items) Refuses to eat (verbally or physically) Stares at food without eating Shows agitated behaviour or irritability Section 4 Oral difficulties and behaviours (8 items) Bites on cutlery (spoon, fork, knife) Holds food or leaves food in the mouth Difficulty chewing www.NHDmag.com May 2016 - Issue 114

NHd-extra: COMMUNITY Step 2. The DMAT system allows you to choose two interventions per eating difficulty and any combination of interventions can be trialled. Limiting the interventions to two should keep the care plan simple and allow more accurate outcome monitoring. Different eating difficulties require different approaches, but generally the first set of interventions are aimed at improved caring techniques. The next set of interventions aims to enhance catering and nutrition support. Further interventions are aimed at adapting the mealtime environment to make it more dementia-friendly, as provided in the example in Table 2. Finally referral to healthcare specialists may be indicated. The DMAT is not a dysphagia tool, but does highlight swallowing difficulties in the ‘Oral Difficulties and Behaviours‘ section on the Initial Measurement Form. The intervention

choices associated with these highlight to care staff the importance of patient safety in regard to certain oral difficulties and levels of risk in dysphagia.15 If any texture modified food is recommended as an intervention, users are also reminded to refer to the national descriptors.16 Step 3. The system will generate a care plan based on the identified eating difficulties and chosen interventions (see Figure 2 for example). The care plan is saved on the system and can be downloaded, printed and shared with health and social care teams. For monitoring, it is recommended to use the DMAT monthly or fortnightly if you have concerns about the individual. Comparisons of previous care plans and results can help measure improvements in eating difficulties.

Table 2: Range of interventions that could be trialled for overcoming the mealtime eating difficulty ‘Stares at food without eating’ Suggested interventions: Stares at food without eating Reassure and remind the individual where they are and what time it is and what they are doing. Check hearing aids or glasses are worn if normally used. Try verbal cues: prompt the individual to initiate eating and offer encouragement. Try manual cues, e.g. placing food or utensils into the person’s hands. Try modelling eating so individual can copy your movements and offer encouragement. Trial using hand over hand or hand under hand technique to initiate and guide self-feeding. Simplify the meal process: place only one plate and one utensil on the table, directly in front of the individual. When the individual is finished with the first dish, replace it with another. Trial sensory cues, especially those involving smell, this can let the person know it is time to eat and help stimulate appetite. Trial using plates with a simple plain design and ensure a colour contrast between the plate and the food (e.g. white food served on a white plate may cause visual problems in identifying the food). Trial a colour contrast between the table or place mat and the plate (e.g. a white plate on a white tablecloth may make identifying the food harder). Note: tablecloths make dining more attractive and may provide the colour contrast required rather than changing the plate. Trial adjusting lighting: People living with dementia tend to need increased light compared to normal; attention should be paid to lighting in rooms where people eat. Try to achieve high levels of illumination whilst still maintaining a homely feel. Note: If seated near a window the outside light may cause glare, making it harder to see the meal, therefore try moving the meal place. If the individual continues not to eat provide feeding assistance and consult with a dietitian for nutritional assessment.

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The DMAT was simple to use and helped identify an individualised treatment plan to target interventions on overcoming the eating difficulties. Figure 2: Example of the DMAT Care Plan

SUMMARY

Maintaining independence at mealtimes by preventing and overcoming mealtime eating difficulties should be a more prominent feature of nutritional care for people living with dementia. A recent systematic review on supporting improved nutrition and hydration in dementia concluded that there was ‘no specific evidence or lack of effectiveness of specific interventions’. The authors also stated, with good judgement, ‘people with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence’.8

The DMAT has not undergone psychometric evaluation for validity or reliability, but provides a much needed resource to quickly and easily capture common eating difficulties that people with dementia may present with. Perhaps more importantly, it provides carers with evidenced-based simple, practical and cost effective interventions to create a care plan to overcome them. The DMAT will continue to be developed and is in the process of becoming involved in research trials. You can try the DMAT yourself with a seven-day trial by signing up on the website www.thedmat.com

References 1 Chang CC, Roberts BL. Feeding difficulty in older adults with dementia. J Clin Nurs. 2008; 17(17): 2266-2274. doi:10.1111/j.1365-2702.2007.02275.x 2 Prince M, Emiliano A, Maëlenn G, Matthew P. Nutrition and Dementia A Review of Available Research.; 2014. doi:10.1155/2012/926082 3 Aselage MB. Measuring mealtime difficulties: Eating, feeding and meal behaviours in older adults with dementia. J Clin Nurs. 2010;19(5-6): 621-631. doi:10.1111/j.1365-2702.2009.03129.x 4 Watson R. The Mokken scaling procedure (MSP) applied to the measurement of feeding difficulty in elderly people with dementia. Int J Nurs Stud. 1996;33(4):385-393. doi:10.1016/0020-7489(95)00058-5 5 Crawley H, Hocking E. Eating Well : Supporting Older People and Older People with Dementia.; 2011 6 Durnbaugh T, Haley B, Roberts S. Assessing problem feeding behaviors in mid-stage Alzheimer’s disease. Geriatr Nurs (Minneap). 1996;17(2):63-67. http:// search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=1996018245&site=ehost-live&scope=site 7 Rivière S, Gillette-Guyonnet S, Andrieu S, et al. Cognitive function and caregiver burden: Predictive factors for eating behaviour disorders in Alzheimer’s disease. Int J Geriatr Psychiatry. 2002;17(10): 950-955. doi:10.1002/gps.724 8 Abdelhamid A, Bunn DK, Dickinson A, et al. Effectiveness of interventions to improve, maintain or facilitate oral food and/or drink intake in people with dementia: systematic review. BMC Health Serv Res. 2016;14(Suppl 2): P1. doi:10.1186/1472-6963-14-S2-P1 9 Whear R, Abbott R, Thompson-Coon J, et al. Effectiveness of Mealtime Interventions on Behavior Symptoms of People With Dementia Living in Care Homes: A Systematic Review. J Am Med Dir Assoc. 2014;15(3): 185-193. doi:10.1016/j.jamda.2013.10.016 10 Allen VJ, Methven L, Gosney MA. Use of nutritional complete supplements in older adults with dementia: Systematic review and meta-analysis of clinical outcomes. Clin Nutr. 2013;32(6): 950-957. doi:10.1016/j.clnu.2013.03.015 11 Chaudhury H, Hung L, Badger M. The role of physical environment in supporting person-centered dining in long-term care: a review of the literature. Am J Alzheimers Dis Other Demen. 2013;28(5): 491-500. doi:10.1177/1533317513488923 12 Vucea V, Keller HH, Ducak K. Interventions for Improving Mealtime Experiences in Long-Term Care. J Nutr Gerontol Geriatr. 2014;33(4):249-324 76p. doi:10. 1080/21551197.2014.960339 13 Volkert D, Chourdakis M, Faxen-Irving G, et al. ESPEN guidelines on nutrition in dementia. Clin Nutr. 2015;34(6): 1052-1073. doi:10.1016/j.clnu.2015.09.004 14 Abbott RA, Whear R, Thompson-Coon J, et al. Effectiveness of mealtime interventions on nutritional outcomes for the elderly living in residential care: A systematic review and meta-analysis. Ageing Res Rev. 2013;12(4): 967-981. doi:10.1016/j.arr.2013.06.002 15 Joliffe J, Chadwick D. Guide to Levels of Risk of Negative Health Consequences from Dysphagia.; 2006 16 NPSA. Dysphagia Diet Food Texture Descriptors.; 2011. www.hospitalcaterers.org/publications/downloads/dysphagia-descriptors.pdf 17 The Dementia Mealtime Assessment Tool Software: https://app.thedmat.com/

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NHD-extra: CONDITIONS & DISORDERS

Joe Alvarez Student, Nutrition and Dietetics, University of Chester Joe is currently studying MSc Nutrition and Dietetics at the University of Chester, with a particular interest in gastroenterology, especially allergies. He is passionate about Paediatrics and hopes to work in an acute setting in London after completing his course.

THE LOW FODMAP DIET IN THE TREATMENT OF IRRITABLE BOWEL SYNDROME

student zone

Irritable Bowel Syndrome (IBS) is a functional disorder of the gastrointestinal tract.1-12 It affects around 11% of the global population10 and is more common in women than men.1,2,11 Studies show that a diet low in FODMAPs (Fermentable, Oligosaccharides, Disaccharides, Monosaccharides and Polyols) can be used to treat IBS. Pooled data estimates that the prevalence in the UK is at 10% using the Rome I or II criteria and up to 19% using the Manning criteria. However, it differs greatly between regions and prevalence is 12% in Northern Europe compared to 21% in South America and 7% in South East Asia.10 Its causes are poorly understood and, therefore, it can be difficult to manage in practice. Clinical trials are also often difficult to draw conclusions from due to the placebo effect.1-2 However, it is thought that there may be increased innervation to the intestine and altered gut motility and symptoms can be triggered by psychosocial factors, but diet can also worsen the effect.8-9 IBS can reduce quality of life dramatically (QOL) with patients reporting symptoms such as; bloating, flatulence, burping, abdominal pain, diarrhoea and constipation (amongst others).1-8 Patients can be subtyped into four categories: constipationpredominant, diarrhoea predominant, mixed IBS or un-subtyped.8 A diet low in FODMAPs has been shown to decrease these symptoms in some patients2-4 and has been shown to be more effective than traditional dietary advice for IBS patients.3,11 NICE guidelines currently state that this diet should be recommended if symptoms continue after following traditional dietary and lifestyle advice for IBS.12

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FODMAPs are short-chain carbohydrates that are poorly absorbed in the small intestine. When undigested, they can enter the distal small bowel and colon where they increase the osmotic load and provide substrate for bacterial fermentation.3-4 This then causes luminal distension and elicits the effects seen in IBS, such as gas production, change in bowel motility and bacterial population alterations. A diet low in these can be used to treat IBS, with some studies showing 80% of patients seeing an improvement in their symptoms.3,4,5 WHAT DOES THE DIET INVOLVE?

The diet involves global restriction of foods containing moderate to high FODMAPs (exemplified in Table 1) in the diet for a set period of time (from six to eight weeks), and then reintroducing each one at varying amounts to test a patientâ&#x20AC;&#x2122;s tolerance.5 Only one food should be reintroduced each week. Patients can be tested for lactose and fructose malabsorption using hydrogen/methane breath testing, as not all sufferers will be intolerant to these.4 Onions and garlic are major triggers of gastrointestinal symptoms in a large proportion of those who suffer with IBS. Therefore, those following the FODMAP diet should initially omit these completely. Although it is impossible to completely avoid all FODMAPs, choosing foods low in FODMAPs is the most important aspect when following this diet.9

Figure 1: Prevalence of IBS according to country10

WHAT DOES THE EVIDENCE SHOW?

The majority of studies demonstrate that avoiding FODMAPs can provide significant symptomatic relief to the majority of IBS patients. However, different studies have generated varying degrees of improvement, with some studies demonstrating an improvement in over 70% of patients3,4,11 and others showing improvements in around 50%.3 The differences may be due to varying symptom criteria used in different studies. The sample size also differs and is sometimes too small to make generalised conclusions and, therefore, these studies lack clinical significance. A recent prospective study of 90 IBS patients confirmed that adherence to the diet significantly decreased the symptoms of IBS in patients. 72% of participants stated that they were satisfied

with the improvement in symptoms, with 62% saying that they had reduced abdominal pain and discomfort. They found that strict adherence to the diet was paramount to ensure success. Adherent participants stated that they saw improvement in an average of 17/20 symptoms compared to just 7/20 in less adherent participants. However, this study found that burping, passage of mucus and the feeling of satiety did not improve after trialling a low FODMAP diet. The study stated that due to proposed mechanism of this diet (as described earlier), this finding was unsurprising.4 The cohort was small and 84% female. Also, the mean age of participants was 47, so overall the study is not generalizable, but is an indication that the diet could possibly provide some symptomatic relief to sufferers.

Table 1: FODMAPs - Examples of food ingredients and commonly consumed foods with that ingredient.9 FODMAP

Example ingredient

Example food

Oligosaccharides

Fructans and galacto-oligosaccharides

Pasta, couscous, bread (all wheat based products), barley and rye based products, onions and garlic

Disaccharides

Lactose

Dairy products: milk, yoghurt, cream, soft cheese

Monosaccharides

Fructose

Fruit, fruit juice, honey, table sugar

Polyols

Sorbitol, mannitol, xylitol, erythritol, lactitol, maltitol, isomalt and hydrogenated starch hydrolysates

Food additives (commonly found in confectionery)

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NHD-extra: CONDITIONS & DISORDERS Another study compared patients on a low FODMAP diet with those who were given standard dietary advice as recommended by NICE. They found that 76% of those on the low FODMAP diet saw an improvement in symptoms compared to 54% of those on the standard diet. 85% felt an improvement in abdominal pain or discomfort compare to 61% who were given NICE advice.11 This consists of limiting fruit intake to three per day, limiting consumption of resistant starch and sugar-free foods (which tend to be high in additives) and controlling insoluble fibre intake.12 IS IT PRACTICAL TO ADVISE IN PRACTICE?

Studies show that patient adherence to the diet is good. Although this is difficult to measure, food diaries and interviewing can be used. One study showed that 75% of participants adhered to the diet for the full period of time. As they saw improvements in symptoms, patients deemed the adherence worthwhile.4 It is vital that patients only remove potential triggers from their diet. They should also receive sufficient information and advice from a registered dietitian about a healthy, balanced diet before initiation. Using breath hydrogen tests to identify lactose or fructose malabsorption can reduce restrictiveness of the diet in the absence of this.5 Fructose malabsorption has been shown to

be present in approximately 40% of IBS sufferers6 with a higher prevalence in those of Northern European ethnicity, whilst lactose intolerance exists in 15-100%6 with a higher prevalence in Hispanic and Black populations.7 It is important to recognise that diet is not the only trigger of symptoms in IBS. Stress and emotions also play a significant role in causing gastrointestinal dysfunction.7 Patients with this disorder tend to have higher levels of depression and anxiety. Therefore, psychotherapy may also play a role in the treatment of IBS. Pharmacological interventions are sometimes required for pain relief in many patients, this may include anti-spasmodics, laxatives (for those with constipation-dominant IBS), tricyclic antidepressants or anti-diarrheal agents (for those with diarrhoea-dominant).8 CONCLUSION

Research suggests that the FODMAP diet is effective in improving symptoms of IBS in some people. Adherence to the diet is generally good and can be measured using food diaries. Hydrogen or methane breath testing could be used to determine if patients are fructose or lactose intolerant to reduce the restrictiveness of the diet for those who are not. Advice and guidance from a dietitian is paramount to ensure that patients are eating a varied, balanced diet.

References 1 Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (2006). Functional bowel disorders. Gastroenterology, 130, pp 148091 2 Heizer W, Southern S and McGovern S (2009). The Role of Diet in Symptoms of Irritable Bowel Syndrome in Adults: A Narrative Review. Journal of the American Dietetic Association, 109(7), pp 1204-1214 3 Böhn L, Störsrud S, Liljebo T, Collin L, Lindfors P, Törnblom H and Simrén M (2015). Diet Low in FODMAPs Reduces Symptoms of Irritable Bowel Syndrome as well as Traditional Dietary Advice: A Randomised Controlled Trial. Gastroenterology, 149(6), pp 1399-1407.e2 4 de Roest R, Dobbs B, Chapman B, Batman B, O’Brien L, Leeper J, Hebblethwaite C and Gearry R (2013). The low FODMAP diet improves gastrointestinal symptoms in patients with irritable bowel syndrome: a prospective study. International Journal of Clinical Practice, 67(9), pp 895903 5 Gibson P and Shepherd S (2010). Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology, 25(2), pp 252-258 6 Shepherd S, Parker F, Muir J and Gibson P (2008). Dietary Triggers of Abdominal Symptoms in Patients with Irritable Bowel Syndrome: Randomised Placebo-Controlled Evidence. Clinical Gastroenterology and Hepatology, 6(7), pp 765-771 7 Rumessen J and Gudmand-Høyer E (1987). Malabsorption of Fructose-Sorbitol Mixtures Interactions Causing Abdominal Distress. Scandinavian Journal of Gastroenterology, 22(4), pp 431-436 8 Hayes P, Fraher M and Quigley E (2009). Irritable bowel syndrome: Role of food in pathogenesis and management. Gastroenterology and Hepatology, 10(3), pp 164-174 9 Shepherd S and Gibson P (2013). The complete low-FODMAP diet. United States, New York. Experiment 10 Lovell R and Ford A (2012). Global Prevalence of and Risk Factors for Irritable Bowel Syndrome: A Meta-analysis. Clinical Gastroenterology and Hepatology, 10(7), pp 712-721.e4 11 Staudacher H, Whelan K, Irving P and Lomer M (2011). Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome. Journal of Human Nutrition and Dietetics, 24(5), pp 487-495 12 NICE (2008). Irritable bowel syndrome in adults: diagnosis and management, Recommendations (CG61)