Network Health Digest - Aug/Sept 2016 - issue 117 by NH Publishing Ltd

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

NHDmag.com August / September 2016: Issue 117

SIZE MATTERS Health behaviours & body respect

SPECIAL INFANT FORMULAS ONS PRESCRIBING BARIATRIC SURGERY MALNUTRITION

Fatty acids & school performance

Kcal Protein

400 20g Vits & Mins Fibre

50% 0 g RNI

NEW

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New Fortisip 2kcal provides 400 kcal and 20 g of protein per 200 ml bottle. Each bottle provides 50% of the RNI for micronutrients.* It also has at least double the level of vitamin D† vs other 2 kcal/ml products.‡ This makes Fortisip 2kcal an ideal 2 kcal/ml product for your patients.

*RNI for males 19–50 years used as a comparator (excluding sodium, potassium, chloride and magnesium). †10 µg vitamin D per 200 ml bottle. ‡Ensure TwoCal (3.4 µg) and Fresubin 2kcal (5 µg) (correct at time of preparation). Date of preparation: 03/16

FROM THE EDITOR

WELCOME . . . Emma Coates Editor

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

This double issue of NHD for August and September is filled with glorious dietetic treats for us all to enjoy whilst hopefully lounging in the sun with a long cool drink. OK, I’m really stretching my imagination here with the British summer having been a bit of a damp squib, but the fantastic articles we have for you this time are definitely real. Dietetics always promotes healthy lifestyle choices and achieving a healthy weight. We have two great articles this issue, with quite contrasting approaches to these goals. An alternative approach comes from Dr Lucy Aphramor who shares her insights into the ‘Well Now’ way, where health gain and body respect become the focus of therapy in healthy weight services. Our second article on weight management is by Maria Dow, Freelance Dietitian, who discusses the clinical nutritional management of the bariatric patient; explaining surgical options and post-operative care required for this patient group. Adult metabolic dietitians, Suzanne Ford (North Bristol NHS Trust) and Louise Robertson (University Hospitals Birmingham NHS Foundation Trust), bring this issue’s IMD Watch to us, focusing on Maple Syrup Urine Disease management in the adult patient. Specialist Dietitian, Maeve Hanan explores a multi-disciplinary approach to malnutrition and we welcome back Rychelle Winstone, Clinical Lead Paediatric Dietitian, with her thorough overview of specialist infant formulas and their use in practice. The handy Reference Table on pages 36-37 is a very useful resource. Don’t miss too, Dr Carrie Ruxton’s look at fatty acid supplements and school performance, with evidence supporting the role these can play in children’s learning and behaviour. We also feature an article from the BSNA on the prescribing of oral nutritional supplements (ONS) in medical management.

The world of freelance dietetics is a growing area where practice should be safe and evidence based. Freelance Dietitian, Anne Wright provides an ethical discussion about the management of cancer care in freelance practice, where boundaries for safe practice are vital in maintaining safety for both practitioner and patient. Be sure to visit our Subscriber zone on our website to access more great articles via our digital supplement NHD Extra: www.nhdmag.com. You’ll find an interesting sports nutrition case study from Helen Phadnis on the dietary management of an experienced climber and some stimulating and curious Food and Drink articles. Ursula Arens delves into the world of energy drinks and Michelle Sadler gets a taste for crickets, locusts and mealworms, as she discusses the use of insect protein in the diet. Also, ever wondered what a meals on wheels nutritionist gets up to throughout the day? Annabelle de la Bertauche, Registered Nutritionist takes us through a Day in the Life of a Meals on Wheels Nutritionist. On top of all that, don’t forget our online Student zone. This month we have a great article from Joe Alvarez, University of Chester student, where men in dietetics are discussed. A must read for Guyatitians! If you are lucky enough to have some time off over the next few weeks, enjoy your summer break and we’ll see you in October for more excellent NHD articles and nuggets of dietetic information. Emma

www.NHDmag.com August / September 2016 - Issue 117

9 COVER STORY

CONTENTS

Size matters: health gain & body respect with the â&#x20AC;&#x2DC;Well Nowâ&#x20AC;&#x2122; way 6

News

Latest industry and product updates

15 Bariatric surgery Procedures and nutritional

management of patients

41 FATTY ACIDS Supplements & school performance 45 ONS prescribing

In disease-related malnutrition

21 IMD WATCH

49 Freelance practice Managing cancer care patients

Maple Syrup Urine Disease

52 Web watch Online resources and updates

25 Malnutrition A multi-disciplinary approach

33 SPECIALISED INFANT FORMULA An overview

54 Events & courses, dieteticJOBS Dates for your diary

& job opportunities

55 The final helping The last word from Neil Donnelly

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

Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie 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

@NHDmagazine

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

www.NHDmag.com August / September 2016 - Issue 117

ISSN 1756-9567 (Print)

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NEWS

FOOD FOR THOUGHT

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

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

Brexit - are RCTs the way to go? Two new papers have been published questioning whether we need more randomised controlled trials (RCTs) within the field of nutrition. At present the number of epidemiological studies heavily outweighs the number of RCTs. One pool of thought is that RCTs often recruit subjects with a history of disease (or an increased disease risk) and have relatively short periods of follow-up. Cohort studies, on the other hand, typically recruit healthy subjects at baseline and have longer periods of follow-up, usually 10 to 15 years. These differences may account for some of the discrepancies we see between the different types of study. The other pool of thought is that RCTs play a valuable role in helping to identifying ‘non-significant’ findings. Whilst some may think that the outlook of this is rather grim, it is in fact a good thing. Lack of findings can actually help in refuting epidemiological associations that may have been hampered by confounders. So, which way to go? Personally, I’d say that we need more RCTs that are adequately designed and fall in line with CONSORT (Consolidated Standards of Reporting Trials) guidelines. That way, outcomes can be compared fairly between studies and firmer conclusions drawn. Also, given the recent Brexit choice, the question is whether collaborative cohorts with European colleagues will still go ahead. Funding sources were challenging enough and certainly won’t become any easier. So, from that viewpoint, perhaps specific well-designed RCTs may be the way to go for now. For more information, see: Loannidis JPA et al (2016); American Journal of Clinical Nutrition Vol 103, no 6; pg 1385-86 and Temple NJ (2016); British Journal of Nutrition Vol 116, no3; pg 381-89.

CRANBERRY JUICE FOR UTIs? It is often thought that cranberry juice is great for urinary tract infections (UTIs). That said, the evidence for this has never really been substantiated. Now, a new randomised controlled trial has tested to see if the science really exists. Women with a history of UTIs (mean age 41 years) were randomly allocated to drink 240ml cranberry juice (n=185), or a placebo

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(n=188) over a period of 24-weeks. The number of UTI episodes was reported throughout. Study compliance was good and the number of UTI episodes was significantly reduced from 67 to 39 (by nearly half) in the cranberry juice compared with the placebo group. Overall, these results show that long-term daily consumption (about one glass per day) of cranberry juice may help to reduce the risk of UTIs in women with a history of this condition. For more information, see: Maki KC et al (2016);

American Journal of Clinical Nutrition Vol 103, no 6; pg 1434-42.

NEWS THE NEED TO ASSESS WATER INTAKES SEPARATELY Water has long been merged in with ‘fluids’ when looking at data from dietary surveys. That said, given the health benefits of drinking water, this ideally needs to be analysed and categorised separately. New work has looked into how water intakes are currently assessed in Europe. A survey of 10 European countries looking at methods used to assess water intakes found great variability in methods. These ranged from 24-hour recalls, to estimated food diaries and food frequency questionnaires. None of these methods had been validated to specifically assess water and fluid intakes. These findings highlight the need to devise uniform and validated methods used to assess water and fluid intakes. This would help to aid comparisons made between countries and support future recommendations. For more information, see: Gandy J et al (2016); British Journal of Nutrition [Epub ahead of print].

MICRONUTRIENT INTAKES IN THE VERY OLD We are an aging population, but past nutrition research hasn’t tended to go beyond the 60 to 65 year age mark. The good news is that researchers from the University of Newcastle have now done this, providing nutrition intake data for the ‘very old’. Nutrient intakes of 75-year-olds living in the North-East of England taking part in the Newcastle 85+ Study were measured using 24hour recalls. Median vitamin D intakes were 2.0µg, calcium 731mg, magnesium 215mg, iron 8.7mg and selenium 39µg per day indicating shortfalls. Of most concern was that 95% of the population had vitamin D intakes below the UKs Reference Nutrient Intake of 10µg per day. These are important and much needed findings, emphasising the need for more research in this age group. Further research of this nature is also needed to support the formulation of agespecific dietary recommendations required for this growing age group. For more information, see: Mendonca N et al (2016); British Journal of Nutrition [Epub ahead of print].

PRODUCT / INDUSTRY NEWS

GLUTEN-FREE BREADS FROM GENERAL DIETARY

These breads are light, soft and can be eaten straight from the pack. The coeliac’s choice since 1983. Free from wheat, gluten, milk, eggs, soya, maize and nuts. They also contain vitamins and minerals including calcium and folic acid. Suitable for vegetarians, vegans and kosher diets. www.generaldietary.com

To book your Company’s product news for the next issue of NHD Magazine call 0845 450 2125 WHAT AGE TO WEAN? While most parents begin weaning their infants at six months, there has been a trend towards early weaning, with the introduction of solids at four months. New research has now looked at how this could affect children’s later eating habits. Research using data from the Southampton Women’s Survey, looked at what age food was introduced compared with feeding difficulties when the children were three years of age, in 2,389 mother-child pairs. Factors such as breastfeeding, the mother’s BMI, age, education and employment were all accounted for. Sixty-one percent of mothers/carers had some form of feeding difficulties when their child was aged three years, with children being choosy most common (74%). Children who were given solid foods at six months of age or later were significantly less likely to have feeding problems compared with those given solids at four to six months. While other studies are needed to reconfirm these results, it seems that holding off from the temptation of early feeding may help children to eat better later on. Next we need to find out why this may be. For more information: www.mrc.soton.ac.uk/sws/

www.NHDmag.com August / September 2016 - Issue 117

ENTERAL NUTRITION

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COVER STORY

THE CASE FOR HEALTH GAIN AND BODY RESPECT IN HEALTHY WEIGHT SERVICES Lucy Aphramor Dietitian, Consultant and trainer, Visiting research fellow University of Chester Lucy Aphramor PhD is committed to bringing compassion and social justice into dietetics’ lifestyle conversation. She is a founder member of Critical Dietetics and nominated to the BDA roll of honour.

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

An increasing number of dietitians are adopting an approach to nutritional wellbeing that promotes health gain and body respect for all, as an alternative to weight management. This shift in focus characterises an approach known as the ‘Well Now’ way. This article explores the rationale behind Well Now’s innovation and illustrates some of its hallmark features in practise. Imagine that Jay comes to clinic with newly diagnosed hypertension. We see her again six weeks later, during which time she has made significant changes to her eating and activity behaviours, taken up mindfulness practise and changed jobs. She told us that her BMI when we first met was in the range 3035. She still has no wish to be weighed and we don’t know if her weight has changed or not. Using the column headings in Figure 1, we can consider how change in behaviours may impact health and whether or not Jay’s weight is reduced. For instance, we know that diet can influence hypertension regardless of weight loss.1 In fact, improved health behaviours impact wellbeing

independently of weight loss across a range of non-communicable diseases (NCDs), such as heart disease and Type 2 diabetes. Jay told us that the reason she changed jobs was that she was being bullied and discriminated against. She feels valued in her new job and team morale is high. But how is this relevant to hypertension? Can respect impact NCDs? There is a vast amount of research showing that how we are treated by society has metabolic consequences.2-5 That is, stress has embodied impact even if health behaviours are unaltered. In acute stress, cortisol is released and when the stress passes, levels of cortisol and adrenaline return to base line. But,

Figure 1: The Well Now Table for untangling health behaviours, respect, weight and wellbeing

NHDmag.com August / September 2016 - Issue 117

www.well-founded.org.uk

WEIGHT MANAGEMENT

Figure 2: Theaway Well Now Cycle Take 5

The Well Now way: respecting every body now speaking kindly to myself

lots of factors impact my life

Feel better about yourself, greater sense of wellbeing

I accept myself as I am

Listening to your body and emotions Learning to trust yourself

Improved body confidence encourages active living

Respect and value yourself “I will take care of myself right now"

I will listen to my body, eat well & nourish myself

Eating is enjoyable & self-nurturing

Start to feel more in control & self-confident practice compassion

health and a healthy society is a fair society. Erasing science on the health impact of stigma (including size-ism, racism, etc) means that explanations for and interventions to alter population distributions of health will be incomplete, misleading and ultimately harmful. Rejecting the pursuit of weight loss is not the same as being against patients losing weight. Instead, it means seeing weight loss as a secondary outcome rather than a primary goal, or reliable indicator of health. Personal health parameters of dietary quality, HbA1C, blood pressure, fitness, mental wellbeing, eating-disorder symptomology and so on, can measure change. WEIGHT SCIENCE: ADVERSE EFFECT

What of the final column? In six randomised controlled trials (RCTs), tuning in for a few looking after minutes myself a health-gain approach teaching size acceptance is associated with health enhancement and is not linked with The Well Now Cycle harm.1 A weight-focused approach, however, is robustly associated with all-cause mortality via yo-yo dieting, likely through its inflammatory when someone lives with chronic stress this potential.7 The British Nutrition Foundation homeostatic mechanism gets overwhelmed. notes: ‘‘…a positive association has consistently This work is Open Access, which means you are free to copy, distribute and display the work as long as you clearly attribute the 6 work to the author,athat you do not use thisof workdysregulation for commercial gain in any form whatsoever, and that you in no way alter, Instead, new state is reached been observed between body weight fluctuation transform, or build upon the work without express permission of the author. For any reuse or redistribution, you must make clear tothat others the predisposes licence terms of this work. A Well Now way worksheet. published in February 2016, byand Lucy Aphramor, UK. someone to First inflammation, all-cause mortality and usually…with insulin resistance and arterial damage, all of coronary mortality in particular. This finding is which are linked to NCDs. Thus, the stress of very robust (p 37).’’8 living with stigma has embodied consequences. A minority of patients will lose weight and In other words, stigma is a social determinant of keep it off when dieting. (Note that the same health. This is one reason we need to tackle size people would be expected to lose weight as a and other stigma. secondary outcome of a health-gain approach). But overall: “one third to two thirds of dieters THE ETHICAL DIETITIAN regain more weight than they lost on their diets. Using an approach that promotes body respect In addition, the studies do not provide consistent for people of all sizes helps reduce size stigma evidence that dieting results in significant health and address body shame. Untangling weight, improvements, regardless of weight change... behaviours and wellbeing, and talking about The benefits of dieting are simply too small and wider determinants of health, supports this the potential harms of dieting are too large for shift. (Figure 2). A narrow emphasis on weight it to be recommended as a safe and effective control can miss the fact that oppression is a treatment.”9 This citation is from a systematic health hazard; respect is a social determinant of review of RCTs of weight management studies 10

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of two year’s duration, which is the best available evidence in the field. Clearly, it turns on its head the conventional belief that we have a safe, reliable, weight loss intervention. As such, it has urgent ethical significance. It is only possible to write guidelines that find in favour of weight loss by ignoring this data. NICE (2014),10 for instance, has a scope that does not capture this study. Dietetic research is not immune to misrepresenting weight science.11

Figure 3: The Well Now Way Kindful Eating cycle

WEIGHT SCIENCE: INEFFECTIVENESS

It may sound unbelievable given the tenacity of the ‘eat less, move more’ mantra, but long-term weight loss is not seen even when people adhere to sustained calorie deficit. In the largest study tracking calorie deficit, the Women’s Health Initiative,12 almost 20,000 women reduced calories for over seven years. The experimental group averaged a daily deficit of 360kcals from baseline and increased activity levels. At the end of the study, neither the control arm nor the experimental arm showed significant weight change: setpoint overrides calorie deficit in determining adult weight. In short, perpetuating out-dated messages about weight loss is unethical and harmful. Dietitians are well placed to advocate for responsible science and advance the message of health-gain and body respect for all. KINDFUL EATING

For someone who cannot recall a time when their eating choices weren’t guided by calories, switching focus to health-gain can feel like a leap into the unknown. If they have alternated periods of cognitive restraint with periods of chaotic eating, they may fear that letting go of a weight focus is tantamount to giving up

on themselves. Packing away the scales is not saying, “Eat with abandonment”. Instead, it is offering someone the chance to learn to eat with attunement, to listen to their appetite and use body signals to guide eating choices. The focus on body respect also contains the second message: you are worthy of respect as you are right now. Reminding patients that health gain can arise from behaviour change with or without weight loss and that people of all sizes deserve respect, supports sustained self-care.1 We can identify several steps in helping someone relate differently to food after a lifetime of diet-mentality thinking. First, if someone is distressed because of their eating, we can explore www.NHDmag.com August / September 2016 - Issue 117

WEIGHT MANAGEMENT

The Well Now Way Connected Eating Flowchart Figure 4: The Well Now Connected Eating Flowchart What am I hungry for?

mainly physical hunger

how hungry am I now?

how hungry do I want to be when I finish eating?

what will meet my needs?

mainly emotional hunger

what am I feeling?

Seeing all foods as morally equal, also known as legitimising foods, is pivotal to breaking the eat-judge-distress cycle. Removing judgement removes barriers to satisfying hunger and so meeting needs.

what's on my comfort menu?

how can I take care of myself right now?

of rules about what they should and shouldn’t eat. For sure, it makes sense for someone with an allergy to avoid an allergen. But judging food as good/bad, healthy/unhealthy ways to break the cycle. An effective way to do this and assigning moral values, is part of the problem is to teach compassion.13,14 Adding compassion to of troubled eating, not the solution. the eat-judge-distress-judge cycle offers a www.well-founded.org.uk way Seeing all foods as morally equal, also known out. When the harsh inner critic starts playing as legitimising foods, is pivotal to breaking the the archived tapes of failure and guilt, we can eat-judge-distress cycle. Removing judgement explore an option to prevent getting caught up removes barriers to satisfying hunger and so in these feelings. This involves noticing emotions meeting needs. The compulsion to eat particular without judging them. No one is denying that this foods dissipates when restrictions are removed is a hard place to be, but accepting this without dieters are more likely to stimulus eat than those judgement enables us to take a step back. It can using a health-gain approach.16 also help to remind ourselves of our common humanity and remember that other people feel CONNECTED EATING this way. Now, someone has accepted the difficult Once someone has new ways of responding emotion, stepped back and can ask themselves, to troubled eating, we can help them look in “What would I feel better for right now?” How more detail at how to choose foods that support would they treat their closest friend? By being wellbeing (Figure 4). warm and understanding, or compassionate, When someone has primarily chosen foods on they have created a window of opportunity for the basis of their nutrient and calorie content, the change.15 The cycle outlined above is the Kindful idea of allowing foods to meet a range of social, cultural and psychological roles alongside any Eating cycle (Figure 3). The Kindful Eating cycle is supported nutritional need can be an eye-opener. This more theoretically by compassion science.15 It is also holistic view of nutrition and health can reduce strengthened when we can help someone let go self-blame, food preoccupation and chaotic 12

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eating and help restore a healthy relationship with food17 (Figure 5). Teaching nutrition in ways that help people make links between what they eat and how they feel will further support eating for wellbeing. Here, paying attention to energy levels, appetite, hunger, mood, gut comfort and so on, is the starting point, and these body signals are then explained in relation to nutrition science. This helps someone make sense of their eating behaviours, reclaim pleasure in eating and make food choices that support their overall wellbeing.1,14,16 CONCLUSION

Figure 5: The Well Now Food for Thought Dinner Plate

So, have the scales had their day? Knowing and monitoring weight is important in clinical conditions, such as for burns patients and in heart failure. But encouraging a weight focus as a route to health in the general population is

harmful and unscientific. Morally and ethically, it behoves us to revisit the evidence and take action. The Well Now way offers an ethical alternative that focuses on health gain and body respect. Evaluation from NHS Highland, where â&#x20AC;&#x2DC;Well Nowâ&#x20AC;&#x2122; underpins the healthy weight strategy, illustrates its effectiveness.17

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CLINICAL

NUTRITIONAL MANAGEMENT OF THE BARIATRIC PATIENT Maria Dow Freelance Dietitian

The aim of this article is to discuss the most common types of bariatric procedures being performed in this country as a treatment option and discuss the long-term nutritional management of patients post-operatively.

Maria is a registered dietitian with 25 yearsâ&#x20AC;&#x2122; 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.

The rise in the number of obese persons in the UK with a BMI >30kg/m2 and <40 kg/m2, appears to have slowed down since 2001. There is, however, a continuing rise in the prevalence of persons with a BMI â&#x2030;Ľ40kg/m2.1 Bariatric surgery is a generic term of weight loss surgery and a treatment option for those persons with severe obesity or obesity with other related comorbidities (see Table 1). It is more effective than any other non-surgical option for weight management, both for weight loss and also weight loss maintenance.2 The number of NHS commissioned bariatric surgery procedures in the UK has increased over the past 10 years, with 470 procedures being carried out in England in 2003/4 and up to 6,500 in 2010.3 The picture also appears to be replicated across the whole of the UK. This figure, however, still represents only about 1% of the number of UK patients who would benefit from bariatric surgery.3

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

RESTRICTIVE PROCEDURES

Adjustable Gastric Band An adjustable silicone band is placed around the upper part of the stomach creating a small pouch. This has the effect of reducing the amount of food that can be eaten at any one time. It also reduces the feeling of hunger by pressing on the surface of the stomach. The diameter of the band and hence the restriction on the stomach, can be altered by either injecting or removing saline through a portal that is under the skin connected to the band. A benefit of the gastric band is that the procedure is relatively non- invasive. If the procedure proves ineffective or complications develop then it is easily reversed.

As the prevalence of severe and complex obesity increases, more patients are looking into surgical weight loss solutions. The most common procedures in the UK are Adjustable Gastric Banding, Gastric Bypass and a relative newcomer, the Gastric Sleeve. It is important that patients are reviewed as part of a multi-disciplinary team, including an experienced surgeon, anaesthetist, clinical psychologist and dietitian. Patients need to be thoroughly assessed as to their suitability for surgery and informed of each procedure, as well as of the risks and benefits. Bariatric surgery is not a guarantee of successful weight loss maintenance and consideration needs to be placed on long-term diet, exercise and behavioural therapy to minimise weight regain. TYPES OF PROCEDURE

Procedures can be done either via open surgery or laparoscopically and can be categorised as either Restrictive or Malabsorptive. Adustable Gastric Band

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CLINICAL Sleeve Gastrectomy

Sleeve Gastrectomy The stomach is divided vertically, which reduces it in size by 75%, thus leaving a narrow gastric tube or â&#x20AC;&#x2DC;sleeveâ&#x20AC;&#x2122;. This permits only small amounts of food and creates a feeling of satiety earlier during a meal. The pyloric valve at the bottom is left and the stomach function and absorption are unaltered. This procedure is irreversible. It is the relative newcomer to bariatric surgery and is growing in popularity. This surgery is a shorter duration than the gastric bypass, which is beneficial for patients with severe heart or lung disease. It can also be used as a staged approach for persons with very high BMIs to reduce their BMI with a view to having a gastric bypass in the future. The Gastric Sleeve is a relative newcomer on the scene, so there is a lack of long-term data. Roux en Y Gastric Bypass

MALABSORPTIVE PROCEDURES

Roux en Y Gastric Bypass The Roux en Y Gastric Bypass is thought to be the preferred surgical procedure worldwide.4 A small pouch is created from the original stomach which remains attached to the oesophagus at one end. The other end is connected to a section of the small intestine. This results in a bypass of the remaining stomach and initial loop of small intestine. It is a malabsorptive procedure in that the anatomical change has an effect on intestinal absorption. Patients with very high BMIs may have most to gain from this type of procedure; however, they are at increased risk of postoperative complications which makes them poorer surgical candidates.5 Intragastric Balloon

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Small Gastric Pouch Pylorus

Duodenum

Excluded Portion of Stomach

Alimentary or Roux Limb

Intragastric Balloon A silicone Intragastric Balloon is an interim measure for achieving weight loss in patients with very high BMIs and whom surgery is deemed high risk. The Intragastric Balloon is placed endoscopically, inflated and designed to float freely in the stomach. It reduces the volume of the stomach and leads to premature satiety which aids weight loss. It is following this weight loss that the patient may be offered further bariatric surgery.

Table 1: Bariatric surgery criteria2 BMI ≥40kg/m2 BMI ≥35kg/m2 with other significant obesity related diseases, e.g. Type 2 diabetes, high blood pressure Person has been receiving or will receive intensive management in a Tier 3 service Person fit for anaesthesia and surgery Person commits to need for long-term follow-up First line option for patients with BMI ≥50kg/m2

HEALTH OUTCOMES FOLLOWING BARIATRIC SURGERY

ADVERSE EVENTS

There is a shortage of direct comparative studies comparing bariatric surgical procedures. Systematic reviews published in 2009 looked into the effectiveness of bariatric surgery and concluded the following:6 • Bariatric surgery is more effective at achieving weight loss than non-surgical weight management in patients with BMI >30kg/m2. • At one year, mean weight loss after gastric bypass was 38% compared to gastric band mean of 21% loss.7 • At 10 years, mean weight loss after gastric bypass was 25% compared to gastric band mean of 13% loss.7 • There were significant improvements to comorbidities such as diabetes and hypertension. Some of these effects are due to the neuroendocrine effects of gastric bypass surgery. Plasma glucose levels return to normal almost immediately post operatively, independent of weight loss.8 By contrast, gastric restriction operations have a positive effect on persons with Type 2 diabetes that are as a result of the weight loss itself and are not immediate.9

Bariatric surgery is not without its risks which are greatest for those with very high BMIs. Steps are taken to reduce these risks, such as weight loss before surgery using the Intragastric Balloon. In the Swedish Obesity Study (SOS),7 there was a 0.25% of death following bariatric surgery. 13% of the SOS cohort had postoperative complications including embolism, thrombosis and wound complications or infections.7 POST-OPERATIVE NUTRITIONAL MANAGEMENT

Patient education on nutritional management following bariatric surgery is key to long-term weight loss and weight loss maintenance. It also reduces the risk of long-term nutritional deficiencies. There are certain nutrients that need to be regarded with interest: Protein It is recommended that the diet include 60-120g protein daily to maintain lean body mass during weight loss. This is especially true for patients who have had malabsorptive procedures, such as the Gastric Bypass, to prevent protein malnutrition.10

Table 2: 10g Protein exchanges11 Food

Cooked weight

Household measure

Meat/poultry

30g

1/3 palm size

Fish flakes

30g

2 tbsp

Eggs

50g

1 medium

Pulses (cooked lentils, kidney beans, chick peas)

90g

Baked Beans (drained)

140g

Milk

3tbsp 3tbsp

200mls

1 cup

Cheese

30g

1 small matchbox

Yoghurt

125mls

Small pot

www.NHDmag.com August / September 2016 - Issue 117

CLINICAL Table 3: Diagnosis and treatment of nutritional deficiencies10 Deficiency

Symptoms

Diagnosis

Treatment

Protein malnutrition

Weakness Decreased muscle mass Brittle hair

Serum Albumin Serum Creatinine

Protein supplements

Calcium/vitamin D

Hypocalcaemia Tetany Tingling Cramping Metabolic bone disease

Total and ionized calcium levels Intact PTH 25-D Bone densitometry

Calcium supplements Oral vitamin D

Vitamin B12

Pernicious anaemia Tingling in fingers and toes Depression Dementia

Blood cell count Vitamin B12 levels

Oral crystalline B12

Folic acid

Macrocytic anaemia Palpitations Fatigue Neural tube defects

Blood cell count Folic acid levels Homocysteine

Oral folate supplements (included in multivitamin)

Iron

Decreased work ability Palpitations Fatigue Pica Brittle hair Anaemia

Blood cell count Serum Iron Ferritin

Ferrous sulphate taken with vitamin C

Vitamin A

Loss of nocturnal vision Xeropthalmia

Blood vitamin A levels

Oral vitamin A

Table 4: Characteristics of weight loss maintainers17,18 Increased physical activity: 60-90 minutes daily Emphasis on low energy dense foods Regular meals including breakfast Reduced portion sizes Monitoring weight and food intake Continued cognitive dietary restraint Good social support

Patients are encouraged to consume protein rich foods that are well tolerated, such as meat, poultry, fish, eggs and dairy. Protein is an important part of good nutrition and an aim is set of around 30g of protein in at least two meals in the day. A summary of 10g protein exchanges can be found in Table 2.11 Dietary protein should be established first, then carbohydrates and then fats. Vitamins and minerals Long-term vitamin and mineral supplementation should be considered in all patients undergoing 18

www.NHDmag.com August / September 2016 - Issue 117

bariatric surgery. Changes imposed anatomically by the gastric bypass procedure do increase the risk of various deficiencies, but there is a longterm risk with each procedure. Supplementation with multivitamins, iron, vitamin B12 and calcium with vitamin D are recommended.12 Vitamin B12 deficiencies can occur, particularly after gastric bypass procedures. Studies have shown that over a third of patients had vitamin B12 deficiency at one year, which reduced slightly two to four years post operatively.13 The risk of vitamin B12 deficiency

The number of people with BMI â&#x2030;Ľ 40kg/m2 continues to rise and it is expected that the number of people choosing bariatric surgery as a weight management option will also continue to rise.

in restrictive procedures such as the Gastric Band and Gastric Sleeve are much less.14 The initiation of vitamin B12 supplementation within six months post operatively is recommended by surgical groups.10 Iron deficiency is common after gastric bypass procedures. Prophylactic iron supplementation is required to reduce the risk of iron deficiency anaemia.15 Vitamin C increases iron absorption and should be used with iron supplements.16 Calcium may inhibit iron absorption and is best not taken at the same time. It is important that patients undergo both clinical and biochemical monitoring for micro and macro nutritional deficiencies after bariatric surgery. This includes glucose, electrolytes, iron/ferritin, vitamin B12, folate, calcium, 25D. This helps to reduce the risk of malnutrition and diagnosis of a nutritional deficiency (see Table 3). PREVENTION AND TREATMENT OF WEIGHT REGAIN

Weight regain is not uncommon and it can be expected that 20-25% of the lost weight will be regained over a period of 10 years.10 Food intake charts show that calorie intakes increase one to two years after surgery which coincides with weight regain data.10 This weight regain could be managed by ensuring that patients adhere to dietary recommendations, increase their physical activity and adhere to behaviour modifications and pharmacological therapy. Characteristics akin to successful weight loss maintenance include conscious control of dietary intake, self-monitoring, social support and physical activity (see Table 4).17,18 In severe post-operative weight regain, there

may need to be investigations into whether the gastrointestinal tract remains anatomically intact, or the integrity of the Gastric Band needs to be investigated. FUTURE RESEARCH

There are few comparative studies that examine the weight loss of different surgical procedures. Indications are that weight loss is greater after Gastric Bypass procedures compared to a Gastric Band, but similar to a Sleeve Gastrectomy. Recruitment continues of the SurgiCal Obesity Treatment Study (SCOTS) trial, which is a longitudinal cohort study of bariatric surgery in Scotland following up all patients undergoing bariatric surgery for 10 years. Outcomes to be investigated include mortality, diabetes incidence, diabetes complications, weight change, surgical complications and quality of life.19 It is an area of weight management that continues to grow and, as dietitians, we welcome new evidence to improve our practice. SUMMARY

The number of people with BMI â&#x2030;Ľ 40kg/m2 continues to rise and it is expected that the number of people choosing bariatric surgery as a weight management option will also continue to rise. This type of surgery is a viable treatment option for patients with severe and complex obesity. It has more successful weight change outcomes long term compared to non-surgical interventions. This translates to favourable outcomes in relation to diabetes and cardiovascular disease management. It also provides an opportunity for patients with high BMIs to experience an improved quality of life. www.NHDmag.com August / September 2016 - Issue 117

- supporting your patients with MSUD from infancy to adulthood *

and

™

are also available to help manage the complex needs

of your patients. Ask your Vitaflo representative for further information about any of our MSUD products or support services.

An introduction to Maple Syrup Urine Disease (MSUD)

A Nestlé Health Science Company ®Reg. Trademark of Société des Produits Nestlé S.A.

The ‘Introduction to MSUD’ is a great way to teach others about MSUD.

We offer a small range of convenient low protein foods.

Chef Neil - Here to help create delicious low protein snacks and meals.

Vitaflo @ Home – Your patients can have their Vitaflo prescription products delivered directly to an address of their choice in the UK and Northern Ireland, free of charge.

A Nestlé Health Science Company ® Reg. Trademarks of Société des Produits Nestlé S.A.

All Vitaflo products listed are foods for special medical purposes and should be used under strict medical supervision. * MSUD gel is suitable for use from 6 months of age. Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool, L3 4BQ Web: www.vitaflo.co.uk

NHD0816

IN ASSOCIATION WITH THE NSPKU

IMD WATCH

MAPLE SYRUP URINE DISEASE IN ADULTS: AN OVERVIEW Suzanne Ford, Dietitian in Metabolic Diseases

Louise Robertson Specialist Dietitian

Suzanne Ford works as a Metabolic Dietitian for Adults at North Bristol NHS Trust. She has been a Dietitian for 21 years, with six of them working in Metabolic Disease. Louise is a Specialist Dietitian working with adults with inherited metabolic disorders, with PKU being her biggest cohort of patients.

Maple Syrup Urine Disease (MSUD) is a rare inherited metabolic disease which affects the catabolism of branched chain amino acids (BCAA): leucine, isoleucine and valine. The treatment for MSUD is a low BCAA diet.1 This article outlines the dietetic treatment of MSUD, focusing on adults, since dietary treatment is lifelong. MSUD is an autosomal recessive disorder (see Figure 2) with a UK incidence of one in 116,000.2 In MSUD, the multi-enzyme complex, branched chain alpha ketoacid dehydrogenase (BCKD) complex, is deficient (see Figure 1). In affected individuals, this results in the accumulation of the branched chain amino acids and their corresponding alpha ketoacids. In high concentrations, these are toxic to the brain, especially leucine. The first stage in leucine, isoleucine and valine catabolism is reversible transamination. The second stage is decarboxylation to the respective alpha ketoacids, and this is the defective step in people with MSUD. The coenzymes for BCKD complex include thiamine pyrophosphate - which is why some individuals respond to thiamine treatment. MSUD is so called due to the smell of burnt sugar, or maple syrup, coming from an affected (untreated) individualâ&#x20AC;&#x2122;s urine. In neonates presenting early with classical MSUD, the smell would be apparent at 48 hours of life (and in ear wax - cerumen - at 12 hours of life). From 2015, the NHS Newborn Screening Programme in England and Wales started screening all babies for MSUD. WHY IS DIETETIC INTERVENTION NEEDED?

High levels of leucine and BCAA metabolites can affect biochemistry, structure and functioning of brain cells within the central nervous system (CNS).3,4

Dietary treatment is needed to minimise exposure to toxic metabolites, by restricting BCAA intake to a level that allows individuals to maintain plasma BCAA concentrations within the targeted treatment ranges. There are also some non CNS related side effects from poor metabolic control. These include recurrent infections, as it is believed that both raised BCAAs and raised ketoacids act as immunosuppressants. The most significant effect on quality of life in MSUD is on intellectual outcomes. Intellectual outcome is most influenced by control in newborns. However, outcomes are also influenced by long-term control and any acute decompensations. Thus, early ongoing dietetic treatment and achieving a quick and appropriate treatment for any metabolic stress is vital. HOW DO BRAIN CHANGES AFFECT INDIVIDUALS WITH MSUD?

Brain changes cause reduced cognitive, psychomotor and social functioning in people with MSUD. This could be due to delayed diagnosis and this effect is demonstrated in a 2006 report on a series of UK patients.5 Published reports (and anecdotal experience) suggest that, currently, adults with MSUD do have reduced social outcomes and social status. German MSUD patients are reported to have low educational attainment and low levels of employment; this group could not live independently, did not have steady interpersonal relationships and had no children.6

www.NHDmag.com August / September 2016 - Issue 117

IMD WATCH Figure 1: MSUD pathway

People with MSUD do need a certain amount of natural BCAA from their diet to keep their blood concentrations within range and prevent protein catabolism. This is often taught to patients and their families using an exchange system whereby one exchange = 1.0g protein or 50mg leucine, (when the leucine content of food is known). The protein restriction is based on leucine rather than other BCAAs, as it appears leucine is the most neurotoxic of the three BCAAs. Leucine tolerance depends on residual BCKD activity, as well as age, gender, life stage, weight and health of the individual with MSUD.

Older MSUD patients who had delayed diagnosis, may have more severe learning disabilities, which can leave them very vulnerable. It is important to ensure that patients are looked after socially and that carers/care home staff are educated on the importance of the diet. WHAT IS THE CURRENT CONSENSUS ON DIETETIC TREATMENT FOR ADULTS WITH MSUD?

The goals of treatment are to achieve appropriate BCAA blood concentrations, ensuring leucine levels are not too high and valine and isoleucine levels are not too low to cause catabolism. The guidelines recommend that plasma BCAA are maintained within the below ranges throughout life. WHAT ARE THE DIFFERENT COMPONENTS OF THE DIET?

If BCAA concentrations are too high, then high protein foods will need to be restricted (e.g. meat, fish, dairy, soya, pulses and nuts).

Protein substitute A BCAA free amino acid supplement is important to avoid protein deficiency and prevent catabolism of muscle leading to high leucine concentrations. The product used depends on patient age and preference. For optimal metabolic control, these amino acid supplements (powders or ready to drink), should be taken throughout the day. The balance between natural protein and BCAAfree supplement is individualised and adjusted to meet growth and development needs. The amount of BCAA free amino acids prescribed must account for inefficiencies in amino acid and protein metabolism, as much as 140% of the RNI for protein may be needed. There is no disorder specific guidance on protein metabolism in MSUD and the proportion of natural protein to amino acid supplement making up total protein needs will vary depending on the severity of MSUD in an individual. Compliance must be monitored, in particular, as individuals may be prescribed significant daily volumes of protein substitute. Amino acids can taste very bitter and acidic. However, people with MSUD need to take these from infancy and might develop a tolerance to the taste.

Table 1: Suggested guidelines for blood BCAA concentrations in MSUD, five-year-olds and older Normal reference range

UK Expanded Newborn Screening2

USA guidelines7

Leucine

65-220

200-400

75-300

Isoleucine

26-100

200-400

Valine

90-300

200-400

300-400

Amino acid (umol/L)

www.NHDmag.com August / September 2016 - Issue 117

Table 2: Exchange examples8 Food

Figure 2: Autosomal recessive inheritance g providing 50mg leucine

Cows’ milk

15mL

Single cream

20mL

Double cream

35mL

Yoghurt

10mL

Custard

15mL

Ice cream

Baked Beans

Broccoli (boiled)

Peas (boiled)

Sweetcorn (tinned)

Boiled/jacket potato

Roast potatoes

Chips

Avocado

Banana

Kiwi fruit

Valine and isoleucine supplements As the natural protein exchange allowance is determined by leucine metabolism, there is a chance that valine and isoleucine intakes become deficient and these amino acids may need to be supplemented separately (although the powdered amino acid could be mixed in with the main protein substitute). Whether to supplement or not and determining the correct dose of these two amino acids will depend on the individual’s plasma amino acid profiles. Additional valine and isoleucine may also be given to promote anabolism of leucine when plasma leucine concentrations are high during illness. 9 Macronutrients and micronutrients are needed as per the relevant DRVs for an individual’s age group, subject to any deficiencies noted during nutritional monitoring of an individual with MSUD. On a reduced protein diet, it is possible that a wide range of nutritional deficiencies occur, such as B12, Essential fatty acids and long-chain polyunsaturated fatty acids.10 Micronutrients are present in the protein substitute, another reason for encouraging compliance.

LOW PROTEIN FOODS

Naturally occurring low protein foods are a cornerstone of the MSUD diet, such as fruit and vegetables. However, low protein foods on prescription (e.g. low protein pasta, bread, flour, biscuits) may be needed to add variety, calories and palatability to the low protein diet. Consistent and adequate energy intake is vital for people with MSUD as catabolism results in raised leucine levels. People with MSUD ideally undergo frequent surveillance of a wide range metabolic and nutritional parameters to ensure that goals of treatment are met, as well as normal growth and development are occurring and that any adverse effects of treatment (deficiencies) are avoided.11 WHY IS AN EMERGENCY REGIMEN NEEDED FOR PEOPLE WITH MSUD AND WHAT IS IT?

During times of metabolic stress (illness, fasting, surgery), leucine concentrations can rise due www.NHDmag.com August / September 2016 - Issue 117

IMD WATCH to protein catabolism leading to a metabolic decompensation. To prevent protein catabolism and promote anabolism, a high carbohydrate intake,7,8,9 alongside the patient’s usual BCAA free protein substitute, should be given. Natural protein should be stopped and extra valine and isoleucine should be supplemented if required to promote anabolism. The BCAA free protein substitute, valine and isoleucine will help promote anabolism and provide a protective effect, stopping some of the leucine from crossing the blood brain barrier. The Emergency Regimen (ER) instructions are to take 200mls of a 25% glucose polymer solutions every two to three hours, day or night, alongside the MSUD amino acid supplement and reduced/no natural protein at the first sign of any illness. The details of each person’s ER depends on their individual requirements (i.e. it is weight/gender/age dependent). If the illness continues after 24 to 48 hours, or if the ER isn’t tolerated, then intravenous dextrose and other supportive treatments, as well as close monitoring, may be needed, so a hospital admission is indicated. Nasogastric feeding might be indicated in order to supply the emergency regimen and MSUD protein substitute if the patient is unable to drink sufficient quantities to bring their leucine levels down. Living with the possibility of metabolic decompensation is reported as burdensome and stressful by families living with MSUD and

similar disorders.12 The emergency regimen is applicable during any period of reduced food intake or period of catabolism and people with MSUD and their families are strongly encouraged to carry around with them both the details of their ER recipe and the ingredients. Emergency regimen information is available in detail from the website www.bimdg.org. WHAT DOES THE FUTURE HOLD FOR PEOPLE AFFECTED BY MSUD?

Our knowledge of MSUD in adults is still in its infancy as the patient cohort is still young. Adolescence is a worrying time when patients are more likely to stray from their diets and experiment with alcohol and drugs. The number of females reaching childbearing age will increase, due to newborn screening. There have been case reports of successful pregnancy in MSUD women.13,14 Careful dietary management is needed during pregnancy as protein requirements increase13 and there is a risk of decompensation if the women suffers from morning sickness, or during a prolonged labour, or if an anesthetic/Csection is needed. We do not know what challenges old age and MSUD will bring. Will this group be affected with other co-morbidities associated with older age and how will this affect their diet? There is a need for a greater understanding of the disease which can help achieve better outcomes for individuals affected with MSUD.

References 1 Ogier de Baulny H, Dionisi-Vici C and Wendel U (2012). Branched Chain Organic Acidurias/Acidaemias (277-296) in Saudubray JM, van den Berghe G and Walter JH: Inborn Metabolic Disease: Diagnosis and Treatment, 5th Ed, Springer, Berlin, Heidelburg 2 www.expandedscreening.org/site/home/metabolic-msud-facts.asp (accessed 2 July 2016) 3 Walterfang M, Bonnot O, Mocelline R and Velakoulis D (2013). The neuropsychiatry of inborn errors of metabolism 4 Klee D, Thimm E, Wittsack HJ et al (2013). Structural white matter changes in adolescents and young adults with maple syrup urine disease. J Inherit Metab Dis 36: 945-953 5 Le Roux C, Murply E, Hallam P et al (2006). Neuropsychometric outcome predictors with adults with maple syrup urine disease. J Inherit Metab Dis 29:201-202 6 Simon E, Schwarz M, Wendel U (2007). Social Outcomes in adults with maple syrup urine disease. J Inherit Metab Dis 30: 264 7 Frazier D et al (2014). Nutrition management guideline for maple syrup urine disease: an evidence and consensus based approach; Molecular Genetics and Metabolism 112; 210-217 8 Dixon M, MacDonald A, White F and Stafford J (2014). Disorders of Amino Acid Metabolism, Organic Acidaemias and Urea Cycle Disorders in Clinical Paediatric Dietetics; Ed Shaw V, 4th Ed, Wiley Blackwell, Oxford 381-525 9 Marriage B (2010). Nutrition management of patients with inherited disorders of Branched Chain Amino Acid metabolism. Acosta P Nutrition Management in Patients with Inherited Metabolic Disorders 10 Mazer LM, Yi SHL and Singh RH (2010). Docosahexaenoic acid status in females of reproductive age with maple syrup urine disease; J Inherit Metab Dis 33:121-127 11 Strauss KA, Wardley B, Robinson D et al (2010). Classical maple syrup disease and brain development: Principles of management and formula design. Molecular Genetics and Metabolism 99: 333-345 12 Grader G, Haege G, Glahn EM et al (2014). Living with an inborn error of metabolism detected by newborn screening - Parents’ perspectives on child development and impact on family life; J Inherit Metab Dis 37: 189-195 13 Stefanie Heiber, Henryk Zulewski, Marianne Zaugg, Caroline Kiss and Matthias Baumgartner (2015). Successful pregnancy in a woman with Maple Syrup Urine Disease: Case Report. JIMD Rep. 2015; 21: 103-107 14 Wessel AE, Mogensen KM, Rohr F, Erick M, Neilan EG, Chopra S, Levy HL, Gray KJ, Wilkins-Haug L, Berry GT (2015). Management of a woman with Maple Syrup Urine Disease during pregnancy, delivery and lactation. JPEN J Parenteral Enteral Nutr. 2015 Sep;39(7): 875-9. doi: 10.1177/0148607114526451. Epub 2014 Mar 11

www.NHDmag.com August / September 2016 - Issue 117

COMMUNITY

MALNUTRITION: A MULTI-DISCIPLINARY APPROACH Maeve Hanan Stroke Specialist Dietitian City Hospitals Sunderland, NHS

Malnutrition is a significant issue in the UK, which has been gaining more attention since the release of the NHS England Guidance in October 2015 ‘Commissioning Excellent Nutrition and Hydration 2015-2018’.1 In the UK, malnutrition is thought to affect more than three million people at any given time and costs the government in excess of £13 billion per year.

Maeve writes a blog called Dietetically Speaking.com which promotes evidence-based nutrition and dispels fad diets and misleading nutrition claims.

It has been found that malnourished patients require roughly twice as many healthcare resources than adequately nourished patients.2,3 Of those at risk or affected by malnutrition, 93% are living in the community, 5% are found in care homes and 2% are found in hospital.1 On an individual level, the consequences of malnutrition can be devastating and can result in a considerably impaired quality of life (see Table 1). Part of my current role involves working in a close MDT within a community setting. I have found this to be extremely useful when treating malnourished patients, as the root causes of malnutrition can be multifactorial (see Table 1); therefore, a holistic approach to treatment tends to improve health outcomes in a patient-centred way.

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

THE ROLE OF THE DIETITIAN

Dietitians are evidently the key healthcare professionals involved in the treatment of malnutrition. We provide expert knowledge into the aetiology of malnutrition, stay up to date with relevant evidence-based guidelines and utilise specific skills of nutritional assessment prior to formulating an individual treatment plan for the malnourished patient. Due to financial constraints, reduced staffing levels can contribute to increased caseload demands; therefore, it is also vital that dietitians are involved in training other healthcare workers so that patients are adequately screened for malnutrition risk in the community.

Appropriate screening improves the quality of dietetic referrals, therefore maximising resources, and also assists in appropriate caseload prioritisation. Improving nutritional screening is a national priority, as the National Institute for Clinical Excellence (NICE) report that: ‘Improving the identification and treatment of malnutrition is estimated to have the third highest potential to deliver cost savings to the NHS’.4 THE ROLE OF THE GP

The GP is often the first point of contact for malnourished individuals, with roughly 10% of patients attending GP practices being affected by malnutrition;5 therefore, their role in identifying this and appropriately referring to Dietetics is crucial. There are various approaches to screening and managing malnutrition in the community; some NHS Trusts use guides such as the Managing Adult Malnutrition in the Community document,5 or other Trust specific management pathways. In terms of medicines management, liaising with pharmacists based at GP surgeries can also be very useful. The GP often plays a key role in treating the underlying reasons for malnourishment, such as: chronic illness, nausea or constipation. Furthermore, communication with GPs can be essential in order to rule out medical red flags, as weight loss is often a warning sign or symptom of an underlying condition. Although nutrition is currently a core part of junior doctor’s first year medical

www.NHDmag.com August / September 2016 - Issue 117

ADVERTORIAL FEATURE

MANAGING MALNUTRITION IN OLDER ADULTS: THE ROLE OF SPECIALISED ORAL NUTRITION SUPPLEMENTS Imogen MckenzieWatson

Dietitian and Medical Nutrition Manager at Abbott, UK

The estimated cost of malnutrition in England in 2011-2012 was £19.6 billion.1 With 32% of people ≥60 years at risk of malnutrition on admission to hospital2 and with malnutrition increasing the length of hospital stays by 30%,1 the impact of malnutrition on an individual, societal and economic level is considerable.1-6,8,9,11 Oral nutritional supplements (ONS) represent a clinical and cost-effective way to manage malnutrition.12,13 THE IMPACT OF MALNUTRITION ON MUSCLE MASS

THE IMPORTANCE OF PROTEIN AND VITAMIN D FOR MUSCLE HEALTH

As healthy older people age, they experience a reduction in muscle mass and strength. The loss of muscle, strength and energy can intensify in older malnourished patients.14 This can lead to:

Reduced intake of protein coupled with a change in muscle protein metabolism in older people can lead to protein deficiency; a recognised risk factor for loss of muscle mass and frailty.19,20

estimated 1.3 million

• Functional impairment, reduced independence and an increased risk of falling and fractures.15 • Poor balance and difficulties in performing activities of daily living.15 • Impaired immune function.16 • Increased mortality.11 • Increased length of hospital stay.6 • Compromised wound healing.17 • Higher chances of complications12, readmissions5 and even death.9,10

from malnutrition,4

○ In a 2012 study, malnourished patients (29%) had

Malnutrition in older

adults is an extremely common problem in the UK1,3 and is set to escalate further due to the ageing population.1 An

people over 65 suffer and 50% of people

admitted to hospital

from care homes are

at risk of malnutrition.2

Nutrition and dietary management play a major role in

helping patients

recover from illness,

longer hospital stays (6.9±7.3 days vs. 4.6±5.6 days, p<0.001) and were more likely to be readmitted within 15 days.9 ○ Mortality was higher in malnourished patients at 1 year (34% vs. 4.1 %), 2 years (42.6% vs. 6.7%) and 3 years (48.5% vs. 9.9%).9

FIGURE 1: AVERAGE MUSCLE LOSS WITH AGEING18 Adapted from: Baier S et al. JPEN 2009;33(1):71-82

particularly when a

patient has become

LEG CROSS SECTIONS

This article has been commissioned and supported by an from Abbott.

25 YEARS

40 YEARS

Older adults have higher protein requirements, particularly when affected by illness,22 however, in the UK, 20% of people ≥ 65 years of age fail to meet the RNI for daily protein intake.6 Older adults are at increased risk of losing lean body mass due to inactivity or bed rest.24 For elderly patients with three days hospitalisation, approximately 1 kg of lean leg mass is lost.24 Poor vitamin D intake is common in older people.25 In 2015, a study by the UK government’s Scientific Advisory Committee on Nutrition found a high prevalence of sub-optimal vitamin D status in older people (65 years and over), with the mean daily intake from dietary sources at 3.3 μg:26 For adults aged 65 years and over the mean intake was 51% of the RNI including dietary supplements.26

malnourished.5,6

educational grant

- The Reference Nutrient Intake (RNI) in the UK for protein in the healthy adult population is 0.75g/kg body weight/ day.21 - The European Society for Clinical Nutrition and Metabolism (ESPEN) recommends at least 1.0-1.2 g protein/ kg body weight/day for healthy older adults. 22 - For certain older adults who have acute or chronic illnesses, 1.2-1.5 g protein/kg body weight/day may be indicated by ESPEN.22

70 YEARS

Vitamin D maintains normal muscle function27 and supplementation reduces the risk of falls28, whilst poor vitamin D status is associated with decreased muscle strength and poor physical performance.28,29

ADVERTORIAL FEATURE Frailty can be increased 4-fold in older people with a poor vitamin D status.30 - RNI for vitamin D for those aged ≥65 years: 400 IU (10 µg)/day31 - European experts recommend that older adults aged ≥65 years meet a mean daily vitamin D intake of 800 IU (20 µg)7 SPECIALISED ORAL NUTRITIONAL SUPPLEMENT ASSOCIATED WITH LOWER DEATH RATES IN MALNOURISHED PATIENTS AGED 65 OR OVER5 The NOURISH (Nutrition effect On Unplanned Readmissions and Survival in Hospitalized patients) trial5 studied the impact of Ensure Plus Advance (high protein, beta-hydroxy-betamethylbutyrate [HMB], vitamin D) vs. placebo on readmissions and mortality through 90 days post-hospital discharge. Ensure Plus Advance was shown to decrease mortality risk. The study did not observe a significant effect for the primary composite endpoint of non-elective readmission or death at 90 days.5

hospital, she is slowly regaining her independence. She says, “Sometimes, people like me who are a little more frail need that extra support. This drink has really helped me to feel stronger.” CONCLUSION The use of multi-nutrient ONS such as Ensure Plus Advance can help to improve clinical outcomes in malnourished older adults. The specialised oral nutritional supplement used in the NOURISH study has been shown to significantly improve health outcomes (nutritional status, body weight and vitamin D levels) within 90 days.* The NOURISH study5 builds upon existing research that shows the vital role specialised nutrition plays in a patient’s health, ranging from rebuilding muscle mass to helping with recovery from disease and time in the hospital.6 *In a clinical trial with over 600 undernourished people with heart or lung diseases, age 65 or older, those using Ensure Plus Advance twice daily significantly improved nutritional status, body weight, and vitamin D levels over standard diet within 90 days of hospital discharge.

KEY RESULTS FROM NOURISH5 TRIAL

REFERENCES

In one of the largest clinical studies of its kind, Ensure Plus Advance significantly improved health outcomes (nutritional status, body weight, and vitamin D levels) within 90 days*. Ensure Plus Advance was shown to reduce the risk of death by 50% through 90 days post hospital discharge in malnourished, cardiopulmonary patients, 65 years or older, as compared to standard nutrition care.

1. BAPEN, 2015: http://www.bapen.org.uk/pdfs/economic-report-full.pdf Accessed June 2016. 2. BAPEN, 2015: http://www.bapen.org.uk/pdfs/nsw/ bapen-nsw-uk.pdf Accessed June 2016. 3. NHS Choices, 2015: http://www.nhs. uk/Conditions/Malnutrition/Pages/Introduction.aspx Accessed June 2016. 4. BAPEN, 2016: http://www.bapen.org.uk/malnutrition-undernutrition/introductionto-malnutrition?showall=&start=4 Accessed June 2016. 5. Deutz N et al. Clin Nutr 2016; Published on-line 18th January 2016. 6. Cawood AL et al. Ageing Res Rev 2012;11(2):278-296. 7. Brouwer-Brolsma EM et al. Osteoporos Int 2013;24(5):1567-1577. 8. Norman K et al. Clin Nutr 2008; 27: 5-15. 9. Lim SL et al. Clin Nutr 2012;31(3):345-50. 10. Gariballa S et al. Clin Nutr 2013;32(5):772776. 11. Vandewoude J et al. J Aging Res 2012;(10):651570. 12. Elia M et al. Clin Nutr 2015;35(2016)125-137. 13. Elia M et al. Clin Nutr 2015;35(2016)370-380. 14. Doherty TJ et al. J Appl. Physiol 2003(95):1717–1727. 15. Roubenoff R et al. J Gerontol 2003;58A(11):1012-17. 16. Marcos A et al. Eur J Clin Nutr 2003;57:S66– S69. 17. Demling RH et al. ePlasty 2009;9:65-94. 18. Baier S et al. JPEN 2009;33(1):71-82. 19. Bartali B et al. J Gerontol A Biol Sci Med Sci 2006;61(6): 589-593. 20. Houston DK et al. Am J Clin Nutr 2008; 87(1): 150-155. 21. Department of Health. Dietary Reference Value for Food Energy and Nutrients for the UK; TSO London 1991, p80. 22. N.E.P. Deutz et al. Clin Nutr 2014;33:929-936. 23. Finch S et al. Europ J Clinical Nutr 1998 (52); 917±9231998. 24. Paddon Jones D. The 110th Abbott Nutrition Research Conference, 2009. 25. Murphy MC et al. Eur J Clin Nutr 2000;54(7):555-562. 26. Scientific Advisory Committee on Nutrition, 2015. https:// www.gov.uk/government/uploads/system/uploads/attachment_data/file/447402/Draft_ SACN_Vitamin_D_and_Health_Report.pdf Accessed June 2016. 27. European Food Safety Authority Journal, 2011;9(9):2382. 28. Wicherts IS et al. J Clin Endocrinol Metab 2007;92(6):2058-2065. 29. In Sayer AA et al. Age Ageing 2013;42(2):145-150. 30. Wilhelm-Leen ER et al. J Inter Med 2010;268(2):171–180. 31. Department of Health, 2012. https://www.gov.uk/government/publications/vitamin-d-advice-onsupplements-for-at-risk-groups Accessed June 2016.

According to Kelly Grainger, Head of Dietetics and Therapies, Leaders in Oncology Care, London: “NOURISH is the first study to show that the use of oral nutritional supplements after discharge significantly reduced mortality rates in the treatment group, as well as improving overall nutritional status as assessed using Subjective Global Assessment”. ONS: GETTING PATIENTS BACK ON THEIR FEET Doreen suffered a serious fall, which led to her spending eight weeks in hospital. During her first weeks in hospital, Doreen lost her appetite, ate very little and lost a considerable amount of weight.

Doreen Mills is an 87-year old female patient who has benefited from Ensure Plus Advance.

Doreen’s clinical team prescribed ‘Ensure Plus Advance’ to aid her recovery. Gradually, as she regained her strength, Doreen started to get her appetite back. Since being discharged from

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COMMUNITY Table 1: Causes and consequences of malnutrition Causes of malnutrition Increased nutritional requirements: Infection Recovery Wound healing Increased activity Frequent involuntary movements Increased losses: Vomiting and diarrhoea Overactive stoma Wound exudate Reduced intake: Poor appetite Nausea Anxiety and depression Pain Illness Dysphagia Food poverty Impaired digestion and/or malabsorption: Drug-nutrient interactions Polypharmacy Bacterial overgrowth Achlorhydria Gastrointestinal medical or surgical problems

Consequences of malnutrition Weight loss Impaired immune response Increased risk of infection Delayed recovery from infections Muscle wasting Delayed rehabilitation from illness Decreased mobility Decrease in ability to perform activities of daily living Increased risk of falls and consequent fractures Reduced respiratory and cardiac muscle function Impaired wound healing Increased risk of wound infection and pressure sores Psychological effects Apathy, depression, anorexia, anxiety, fatigue, low self-esteem and self-neglect Vitamin and mineral deficiencies Increased risk of: thromboembolism, heart failure and hypothermia Impaired gastrointestinal structure and function Poor fertility and pregnancy outcomes Impaired cognitive development in children Decreased quality of life Overall delayed recovery from illness Greater risk of mortality

Table adapted from the Manual of Dietetic Practice 5th edition.

training, further training at GP level may be useful in some areas to highlight the importance of dietetic treatment for malnourished patients. THE ROLE OF NURSES AND HEALTH CARE ASSISTANTS (HCAS)

Monitoring for malnutrition is supported by the Royal College of Nurses (RCN) principles of nursing.6 As 35% of patients admitted to care homes have been reported to be affected by malnutrition in the UK,1 Nurses and HCAs perform the vital role of monitoring for malnutrition and carrying out nutritional screening in this setting. Nursing staff also have frontline daily interactions with patients, which fosters an important understanding of the patient’s overall condition, including nutritional factors such as: bowel habits, mood, skin integrity, weight history, food preferences, ability to self-feed and current oral intake. In a care home setting, the importance of working closely with catering staff as well as

nursing staff shouldn’t be underestimated, as the catering team can provide fortified meal options presented in a palatable manner to maximise the nutritional intake of the residents. Liaising with specialist nurses such as Tissue Viability Nurses and Diabetes Specialist Nurses can also be vital when managing risks associated with malnutrition, such as poor skin integrity or altering insulin regimens when carbohydrate intake has reduced. Where malnourished individuals live in their own home, District Nurses can be a useful point of contact. SPEECH AND LANGUAGE THERAPY (SALT)

SALT has a fundamental role in assessing a patient’s swallowing function in order to recommend the safest texture for diet and fluid intake. In some cases, this can promote nutritional intake via ease of ingestion. However, in other cases, texture modified diets can be found unpalatable. In cases where an individual doesn’t have a safe route for oral feeding, decisions need www.NHDmag.com August / September 2016 - Issue 117

LITTLE THINGS CAN MAKE A BIG DIFFERENCE FOR WINSTON, THAT’S PLAYING SOME CLASSIC JIMMY REED You can keep this a reality with Ensure Compact • Great taste1 • 99% compliance2 • Low volume, 125 ml (2.4 kcal/ml, 13 g protein)

REFERENCES 1. Data on File. Abbott Laboratories Ltd., 2013 (Ensure Compact Palatability Research). 2. Data on File. Abbott Laboratories Ltd., 2013 (Ensure Compact Compliance Research). Date of preparation: October 2015 RXANI150237a

COMMUNITY to be made between the patient, family members, GP, SALT and Dietetics to determine whether enteral feeding or pragmatic oral feeding recommendations in acceptance of aspiration risks are in the patient’s best interests. Working with SALT to ensure maximum fortification of texture modified options can greatly increase a patient’s nutritional intake. Where appropriate, SALT can provide dysphagia therapy to help to improve a patient’s swallow function; studies have found that this can significantly improve nutritional intake.7 If a patient has communication difficulties, SALT communication therapy can be a vital aspect of improving a patient’s mood, which may in turn result in an improved appetite. Use of communication aids as advised by SALT can also be very useful to improve the exchange of information as part of nutritional care planning. OCCUPATIONAL THERAPY (OT)

OT’s involvement in supporting meaningful engagement in activities can greatly affect an individual’s mood and enthusiasm, which can have a positive effect on appetite. From a functional point of view, strategies and equipment to improve self-feeding and independent meal preparation can greatly enhance a person’s overall intake. Examples of specific feeding equipment include: easy-grip cutlery, non-slip mats, keep-warm plates and deep rimmed plates. Enjoyment related to eating and drinking can be increased by modifying the dining environment by providing pleasant tablecloths, ensuring tables are at an appropriate height, limiting background noise and encouraging a social environment for meal times. Issues with memory and cognition may impair meal planning and preparation; therefore, strategies for meal scheduling can also be really useful when individuals are struggling in this respect. PSYCHOLOGY

As there is a well-established connection between food and mood and a strong correlation between depression and malnutrition,8,9 working with clinical psychologists can be extremely useful in terms of resolving malnutrition when mental health issues are present. Training provided by

psychologists for dietitians in techniques related to behaviour change, such as motivational interviewing and cognitive behavioural therapy, can be invaluable for improving patient interaction and helping patients to implement important lifestyle changes, including prioritising their nutritional intake. PHYSIOTHERAPY

Nutrition and physical function go hand in hand, as a poor nutritional status can lead to muscle wasting and low energy levels which can impair mobility, increase falls risk and impair engagement in physiotherapy. Equally, poor mobility and movement can impair a patient’s mood, independence and ability to self-feed, which can lead to an impaired appetite and nutritional status. Furthermore, physiotherapy recommendations for transfers and mobility are important to be aware of when deciding the most appropriate method of monitoring a patient’s anthropometry, such as deciding which type of weighing scales to use or opting to monitor hand grip strength or mid-upper arm circumference for bed bound patients. SOCIAL WORK

Liaising with social work can be important in order to improve an individual’s level of support with activities of daily living, including meal provision and assistance with feeding. Living in a safe, well supported and positive environment with a suitable care package in place promotes the best possible setting to maximise nutritional outcomes. Carers can also provide insightful information into a patient’s food preferences and eating habits in order to improve their dietary intake. CONCLUSION

There is a vast network of support available for malnourished patients from a variety of healthcare professionals in the community. It is essential that dietitians are aware of the scope of each professional’s role and how we can work together synergistically as part of an MDT, with the ultimate aim of tackling malnutrition in the community and improving our patients’ overall wellbeing and quality of life. www.NHDmag.com August / September 2016 - Issue 117

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 lowâ&#x20AC;&#x201C;birthweight infants. Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50:85â&#x20AC;&#x201C;91.

PAEDIATRIC

SPECIALISED INFANT FORMULA: AN OVERVIEW Rychelle Winstone, Clinical Lead Paediatric Dietitian, Hywel Dda Health Board

Rychelle is a Paediatric Dietitian with a special interest in Inherited Metabolic Disease (IMD). She recently left the IMD team at the Evelina London Children’s Hospital and relocated to Pembrokeshire.

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

Paediatric dietitians manage infants in a variety of settings, with a diverse range of clinical conditions and nutritional requirements. Although breastfeeding is best, in some cases a mother may be unable to continue feeding and may make the decision to partially or completely discontinue. It is well established that breastfeeding is the best sole source of nutrition from birth to six months of age and should be continued alongside weaning foods for as long as the mother wishes to do so.1 In very rare cases, breastfeeding may be contraindicated, but in most clinical conditions it can be maintained alongside dietary management.2 In infants with no other clinical concerns that are not fully breastfeeding, over-the-counter standard infant formulas are used. Manufacturers attempt to match these products as closely as possible to breast milk, although the many living components and benefits of breast milk are impossible to replicate.3 The composition of standard infant formulas must comply with the Infant Formula and Follow-on Formula Regulations (2007); there are also strict rules which apply to marketing and advertising.3 In cases where a standard infant formula is not appropriate, it is the job of the Paediatric Dietitian or managing healthcare professional to suggest an appropriate, specialised alternative that meets the infant’s needs. These products are regulated, but come under different legislation than standard infant formula as they are classified as ‘Foods for Special Medical Purposes (FSMP)’.4 Previously, the FSMP Directive (1999/21/EC) governed specialist infant formulas; however, from this year, a new regulation will come into effect: Regulation on Foods for Specific Groups (FSG) (EU 609/2013).4 The supplementary regulation specific to specialised infant formulas: (EU)

2016/127; will apply from February 2020 (February 2021 for protein hydrolysate formulas);5 therefore, manufacturers are likely to make changes to packaging and composition as they prepare for this. This article will summarise some of the indications for the use for specialised infant formulas, with the relevant products available in the UK listed in Table 1. There are, however, many other specialised products in use for various other clinical conditions that are not covered. FOOD HYPERSENSITIVITY

Food hypersensitivity is a broad area incorporating both allergic and nonallergic responses to food and is one of the most common reasons why a specialised infant formula will be prescribed for an infant. Nevertheless, due to the number of products available and varying associated symptoms, there can be some confusion in identification and management. Training of general practitioners and other health professionals is vital and paediatric dietetic referrals should be made where appropriate. This helps to ensure promotion of breastfeeding where possible and that the correct specialised formula is prescribed and reviewed in a timely manner. Cows’ milk protein allergy (CMPA) CMPA is an immune mediated reaction to the protein found in cows’ milk. It affects approximately 7% of formula and mixed-fed infants6 and a much lower proportion of exclusively breastfed infants (0.5%).7 CMPA can be further categorised into IgE-mediated

www.NHDmag.com August / September 2016 - Issue 117

FROM BIRTH The No.1 Amino Acid-Based Formula in the UK • Fast and effective resolution of symptoms in 3 to 14 days1,2 • Enables growth3,4 • Optimal nutrient profile5,6 • Superior palatability7

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1-10 YEARS

1. De Boissieu D, Matarazzo P, Dupont C.J Pediatr 1997;131(5):744-747. 2. Vanderhoof JA, Murray MD, Kaufman S et al. Jpediatr 1997;131 (5): 741-744. 3. Niggemann B, Binder C, Dupont C et al. Pediatr allergy immunol 2001;12(2):78-82. 4. Isolauri E, Sütas Y, Makinen-Kiljunen S et al. J. Pediatr 1995;127(4):550-557. 5. Commission Directive 1999/21/EC (FSMP) and Commission Directive 2006/141/EC (as laid down in the infant formulae and follow-on formula guidelines). 6. Codex Stan 72 –1981 (revision 2007). 7. Data on file 2013, Neocate LCP vs Nutramigen AA

PAEDIATRIC (rapid onset), non-IgE mediated (delayed onset), or mixed. Infants can display a wide range of symptoms with varying severity.8 In a majority of cases, breastfeeding remains the best way to feed an infant with IgE or non IgE mediated cows’ milk protein allergy4 and can usually be successfully managed with maternal exclusion of cows’ milk protein, along with vitamin D and calcium supplementation.8 In formula, or partially breastfed infants, a hypoallergenic infant formula will need to be prescribed:8 Extensively hydrolysed infant formulas (eHFs): enzymes, heat, pressure and ultrafiltration4 are used to break protein molecules into small pieces (<3000Da) which are less likely to mount an immune response.9 It is estimated that around 90% of infants with CMPA should tolerate an eHF.8 The protein faction may be whey or casein based and the formula may contain lactose to improve palatability. One company has added probiotics to their formulation (see Table 1). EHFs are around a third of the price4 of amino acid formulas (AAFs) (see below). Of note, some eHFs contain medium-chain triglycerides, which are indicated in malabsorptive conditions and not usually used in first line food allergy treatment; however, they have been listed in Table 1. Amino acid infant formulas (AAFs) The protein faction in this group of formulas is made up of individual amino acids. They are generally used for infants who have not tolerated eHFs or who have severe symptoms.8 Lactose intolerance Lactose-free infant formula differs from standard infant formula in that the carbohydrate source is glucose rather than lactose. These formulas are aimed at infants with lactose intolerance; however, it is important that the clinical condition is defined and the formula prescribed appropriately. For instance, they should not be recommended to treat colic.10 In the rare incidence of congenital lactose intolerance in an infant, a lactose-free formula would need to be prescribed promptly11 and continued long term. Secondary lactose intolerance resulting from damage to the small bowel and a subsequent reduction in lactase

production can occur after gastroenteritis or prolonged diarrhoea.12 This is likely to be temporary and should resolve two to four weeks after the infection.11 Using lactose-free infant formula to treat acute diarrhoea or gastroenteritis has been shown to provide little clinical benefit.13,14 However, it may be used clinically as a temporary measure to manage symptoms.11 A NOTE ON SOYA FORMULA In the UK, there is one soy protein-based infant formula (soya formula) available to buy over the counter. Whilst this formula meets compositional regulations, and has been shown to support normal growth and development in healthy term infants15, it is not recommended for infants under six months of age.16 This is due to concerns that high levels of phyto-oestrogens present may pose a potential risk to future reproductive health.17 Additionally, soya formula is not an appropriate treatment for cows’ milk protein allergy (CMPA), as a significant proportion of these infants will also be allergic to soy protein.16 Soya formula is routinely used in the management of galactosaemia. Infants with this inherited condition cannot metabolise galactose, a constituent of lactose, and it is one of the few conditions for which breastfeeding is contraindicated.18

MANAGEMENT OF PRETERM INFANTS

Preterm infants are defined as being born before 37 weeks completed gestation.19 They are a very vulnerable group of patients and early nutritional management, along with close monitoring, is imperative to promoting positive short- and longterm health outcomes.4,19 Nutritional needs and the mode of feeding required in this group depends upon many factors including gestation and birth weight; for instance, infants less than 30 weeks gestation will usually require some parenteral nutrition (PN) while enteral feeds are gradually increased.19 Three international publications are available for preterm nutrition and are used in the UK.20,21,22 However, there are still many unknowns in this area and practices vary.4 What is universally agreed is that breast milk is particularly important for preterm infants, ideally expressed from the infant’s mother, or donated breast milk if available. Breast milk provides a raft of benefits, including a reduced risk of necrotising enterocolitis (NEC), among other comorbidities.19 www.NHDmag.com August / September 2016 - Issue 117

Johns.)

SPECIAL INFANT FORMULAS REFERENCE TABLE

www.NHDmag.com August / September 2016 - Issue 117

SPECIAL INFANT FORMULAS REFERENCE TABLE

www.NHDmag.com August / September 2016 - Issue 117

THIS IS HUGE After months of coping with the sleepless worry and heartbreaking cries of his cow’s milk allergy, suddenly, a little moment like this doesn’t seem so little after all. • Proven efficacy – hypoallergenic and has been shown to relieve symptoms1,2 • Proven to be well tolerated – 96% of infants tolerated Similac Alimentum3 • Palm oil and palm olein oil free – supports calcium absorption and bone mineralisation4 SIMILAC ALIMENTUM. FOR BIG LITTLE MOMENTS.

REFERENCES: 1. Sampson HA et al. J Pediatr 1991;118(4): 520-525. 2. Data on file. Abbott Laboratories Ltd., 2013 (Similac Alimentum case studies). 3. Borschel MW and Baggs GE. T O Nutr J 2015;9:1-4. 4. Koo WWK et al. J Am Coll Nutr 2006;25(2):117-122. IMPORTANT NOTICE: Breastfeeding is best for babies, and is recommended for as long as possible during infancy. Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional. Date of preparation: July 2015 RXANI150143

PAEDIATRIC Breast milk fortifiers Breast milk in satisfactory amounts is likely to be nutritionally adequate for infants born at >33 weeks gestation.19 For those born at <33 weeks, breast milk fortifiers are designed to add extra protein and micronutrients to expressed breast milk (EBM) to aid in meeting their increased nutritional requirements.19 It is important that fortifiers are added to the minimum amount of EBM possible; prolonged storage is suspected to cause disruption to immunological components.19 Breast milk fortifiers are only used in a hospital setting, although continued use has been investigated.19

that of a preterm and term formula.19 They are prescribable up to six months corrected age,19 and ESPGHAN recommends their use up to 40 to 52 weeks post-conceptual age.23 However, regular review is needed to ascertain the appropriate period an individual infant requires. The evidence for long-term benefits of post discharge formulas is not consistent, a Cochrane review from 201224 found no evidence for improved growth outcomes at 12 to 18 months age; however, one of the trials with contrary results may have skewed the overall conclusion.19

Preterm formulas For preterm infants <2,000g birth weight and <35 weeks gestation who cannot be fully fed with expressed breast milk and where donor breast milk is not available, preterm infant formulas are used.19 The composition of these formulas is based on published recommendations,21,22 and aim to meet the increased requirements of preterm infants by containing more energy, protein and carbohydrate than breast milk or term infant formula and significantly higher levels of certain micronutrients.4 Micronutrient levels vary between the available formulas in the UK. Preterm formulas are designed to be used in a hospital setting and are available on prescription in a sterile readyto-feed form. Two available formulas have a hydrolysed protein source and, although there is currently no evidence supporting the use of hydrolysed infant formulas in preterm infants,4 it may be indicated in certain infants who are not tolerating a standard preterm formula and who are not candidates for donor milk.19 It is important to note that these hydrolysed preterm formulas are not suitable for the management of cowsâ&#x20AC;&#x2122; milk protein allergy.

There are a number of ways that a Paediatric Dietitian can support catch up in an infant whose growth is faltering. If an infant is breastfeeding it is important to optimise this. Expressed breast milk can also be fortified with standard infant formula to increase nutrient density. In formulafed infants, strategies used to increase nutrient density include concentrating standard infant formula, or prescribing a ready-to-feed high energy formula. High energy infant formulas have a higher energy, protein and micronutrient content than standard infant formula and a higher protein: energy ratio. They only come in ready-to-feed form in the UK and need to be prescribed. Although they can be a handy tool to improve growth in infants, these formulas should be used with caution and regular monitoring. Evidence for their use is limited,4 and there is widespread discussion about the potential impact of early rapid catch-up growth and future long-term health risks, particularly obesity.25 Gradual introduction of high energy formulas should be considered to ensure tolerance. High energy infant formulas are also used in children with increased energy requirements, infants unable to take large volumes of feed and those who require fluid restrictions.

Post-discharge formulas When a partially or fully formula-fed preterm infant is discharged from hospital, they will usually be transitioned onto a post discharge formula. These were developed following observations that preterm infants often demanded very high volumes of term formula which was difficult for carers to manage.19 The nutritional composition falls between

FALTERING GROWTH

GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)

Regurgitation of feeds, otherwise known as gastro-oesophageal reflux (GOR), is a common occurrence in infants and usually begins before eight weeks of age, becoming less frequent with time.26 Further investigation or treatment is not www.NHDmag.com August / September 2016 - Issue 117

PAEDIATRIC feeds.26 Anti-reflux infant formulas with added thickeners, such as rice starch, corn starch or carob bean gum, have been developed for use in these circumstances. The fact that these formulas are widely available over the counter in the UK means that there is the potential for them to be used in simple GOR which is not recommended.26 Manufacturers also often recommend that anti-reflux formula is made up with cold or hand hot water to prevent lumps from forming. Care should be taken as using water less than the recommended 70˚C could compromise food safety.4 needed unless it is associated with distress, projectile vomiting, feeding difficulties and/ or faltering growth. It is then known as gastrooesophageal reflux disease (GORD).26 In formula-fed infants with GORD, a trial of a thickened infant formula is recommended, but only after full assessment and other advice has been given such as smaller, more frequent

IN CONCLUSION

Specialised infant formulas can be used successfully in a variety of clinical conditions, and in some they are a mainstay of treatment. However, it is important that their use is appropriate, reviewed regularly, breastfeeding is promoted where possible and that parents have the correct equipment and are taught safe preparation techniques.

References 1 World Health Organisation (2003). Global Strategy for Infant and Child Feeding. Geneva: WHO. Available at: http://apps.who.int/iris/bitstream/10665/42590/1/92415 62218.pdf?ua=1&ua=1 (accessed May 2016) 2 World Health Organisation (2009). Acceptable medical reasons for use of breast-milk substitutes. Geneva: WHO 3 First Steps Nutrition Trust (2016). Infant Milks in the UK: A Practical Guide for Health Professionals. Available at: www.firststepsnutrition.org/pdfs/Infant_Milks_ February2016.pdf (accessed May 2016) 4 First Steps Nutrition Trust (2015). Specialised Infant Milks in the UK: Infants 0-6 months. Information for Health Professionals. Available at: www.firststepsnutrition. org/pdfs/Specialised_infant_milks_Infants_0-6_months_final.pdf (accessed May 2016) 5 British Specialist Nutrition Association Ltd. Legislation. Available at: www.bsna.co.uk/legislation/ (accessed June 2016) 6 Caffarelli C, Baldi F, Bendandi B et al (2010). Cows’ milk protein allergy in children: a practical guide. Italian Journal of Pediatrics; 36(5) 7 Vandenplas Y, Brueton M, Dupont C et al (2007). Guidelines for the diagnosis and management of cows’ milk protein allergy in infants. Archives of Disease in Childhood; 92(10): 902-908 8 National Institute for Health and Clinical Excellence (2015). Cows’ milk protein allergy in children. Available at: http://cks.nice.org.uk/cows-milk-protein-allergy-inchildren (accessed May 2016) 9 Ludman S, Shah N and Fox A (2013). Managing cows’ milk allergy in children (clinical review). British Medical Journal; 347: f5424 10 Lucassen PL, Assendelft WJ, Gubbels JW, et al (1998). Effectiveness of treatments for infantile colic: systematic review. British Medical Journal; 316: 1563-1569 11 MacDonald S (2015). Gastroenterology. In: Shaw V (Ed). Clinical Paediatric Dietetics (4th edition). Wiley Blackwell Publishing 12 Committee on Nutrition of the American Academy of Pediatrics (2006). Lactose intolerance in infants, children and adolescents. Pediatrics; 118: 1279-1286 13 Kukuruzovic R, Brewster D (2002). Milk formulas in acute gastroenteritis and malnutrition: a randomised trial. Journal of Paediatrics and Child Health; 38(6): 571-577 14 Lee KS, Lee JH (2012). Clinical applications and limitations of a special formula for diarrhea in children. Journal of the Korean Medical Association; 55: 551-561 15 Mendez M, Anthony M, Arab L (2002). Soy-based infant milks and infant growth and development: a review. The Journal of Nutrition; 132: 2127-2130 16 Agostoni C, Axelsson I, Goulet O et al (2006). Soy protein infant milk and follow-on infant milk: A commentary by the ESPGHAN Committee on Nutrition. Journal of Pediatric Gastroenterology and Nutrition; 42: 352-361 17 Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (2003). Phytoestrogens and Health. Available at: http://cot.food.gov.uk/pdfs/ phytoreport0503 (accessed May 2016) 18 MacDonald A, Portnoi P (2015). Disorders of Carbohydrate Metabolism: Galactosaemia. In: Shaw V (Ed). Clinical Paediatric Dietetics (4th edition). Wiley Blackwell Publishing 19 King C, Tavener K (2015). Preterm Infants. In: Shaw V (Ed). Clinical Paediatric Dietetics (4th edition). Wiley Blackwell Publishing 20 Koletzko B, Poindexter B, Uauy R (Eds) (2014). Nutritional Care of Preterm Infants: Scientific Basis and Practical Guidelines. World Rev Nutr Diet. Basel, Karger; vol 110: 4-10 21 Agostoni C, Buonocore G, Carnielli VP, et al (2010). Enteral Nutrition Supply for Preterm Infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee (ESPGHAN). Journal of Paediatric Gastroenterology and Nutrition; 50, 1-9 22 Tsang RC, Lucas A, Uauy R, Zlotkin S (2005). Nutritional needs of the preterm infant: scientific basis and practical guidelines. Baltimore: Williams & Wilkins 23 Aggett P, Agostoni C, Axelsson I et al (2006). Feeding preterm infants after hospital discharge. A commentary by the ESPGHAN Committee on Nutrition. Journal of Pediatric Gastroenterology and Nutrition; 42: 596-603 24 Young L, Morgan J, McCormick FM, McGuire W (2012). Nutrient-enriched infant milk versus standard term infant milk for preterm infants following hospital discharge. Cochrane Database of Systematic Reviews 2012, Issue 3. 25 Pearce J, Langley-Evans S (2013). The types of food introduced during complementary feeding and risk of childhood obesity: a systematic review. International Journal of Obesity; 37: 477-485 26 National Institute for Health and Care Excellence (2015). Gastro-oesophageal Reflux Disease: Recognition, Diagnosis and Management in Children and Young People. NICE Guideline. Available at: www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-recognition-diagnosis-and-management-inchildren-and-young-people-51035086789 (accessed May 2016)

www.NHDmag.com August / September 2016 - Issue 117

NUTRITIONAL SUPPLEMENTS

FATTY ACID SUPPLEMENTS AND SCHOOL PERFORMANCE Carrie Ruxton PhD, Freelance Dietitian, Cupar, Scotland

Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods.

This article was funded by Equazen, manufacturers of evidence-based fatty acid supplements for all ages. The article reflects the opinion of the author.

There is emerging evidence that diet not only affects the structure of the brain, but can influence functional aspects such as memory, learning and behaviour.1 All of these may have a role in school performance. Of all the dietary candidates supporting cognitive function, most interest has been devoted to long chain omega-3 fatty acids (LCn3PUFA), which include docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). This makes sense, as the brain has a high lipid and DHA content. Grey matter is 36-40% lipid with around 15-20% of this estimated to be DHA,2 white matter is 49-66% lipid, while myelin has the highest lipid content at 78-81%.3 There is far more DHA than EPA in brain tissues, but while DHA is thought to be vital as a structural fatty acid, EPAâ&#x20AC;&#x2122;s role is potentially just as important in modulating mood, neural signalling and inflammation.4 A major role of LCn3PUFA in the brain is to increase membrane fluidity which enhances glucose uptake and the transmission of information between neurones.5 In animal models of LCn3PUFA deficiency, detrimental effects on learning, memory and behaviour have been seen, while early work on the fatty acid content of formula milk revealed that inadvertent restriction of DHA and arachidonic acid in infantsâ&#x20AC;&#x2122; diets produced detrimental effects on IQ and vision.6 Low blood levels of LCn3PUFA have been found in children with attention deficit disorders and, while the association does not confirm cause and effect, fatty acid supplements that include LCn-3PUFA have demonstrated modest positive effects on behaviour and learning in children

with these conditions.7 In addition, in normal healthy children, better LCn3PUFA status has been associated with decreased levels of inattention, hyperactivity, emotional and conduct difficulties and increased levels of prosocial behaviour.8 Given the interest in helping children and young people to achieve their educational potential, this article will look at recent studies which have tested the impact of fatty acid supplementation in healthy children. The results of a consumer survey on the learning environment at home, commissioned by Equazen, will also be discussed. REVIEW OF STUDIES

A literature review was conducted on Medline to locate all randomised controlled trials published in the last 15 years, in which LCn3PUFA supplementation had been offered to healthy children. Various cognitive and learning performance indicators were used as outcomes and are summarised alongside the studies in Table 1. It can be seen that in seven out of nine studies, some, if not all, of the children benefited from increased LCn3PUFA intakes. Interestingly, children tended to benefit more often if they were underperforming, or if their baseline LCn3PUFA status was low. This makes sense, as it suggests that improving fatty acid status helps children to achieve their potential.

www.NHDmag.com August / September 2016 - Issue 117

NUTRITIONAL SUPPLEMENTS Table 1: Summary of randomised controlled trials Ref no.

Participants

Intervention details

Statistically significant findings

N=616, infants

Tuna oil from around 6 months to 5 years. Academic performance followed up until 14 years.

Nationally standardised academic performance better in children with higher plasma LCn3PUFA, but no other significant differences.

N=409, 3-13y indigenous Australians

DHA/EPA (0.75g/d) + GLA for 20 wks Improvement in Draw-A-Person followed by placebo group switching test in intervention group. No treatto active intervention for 20 wks. ment effect for reading or spelling.

N=396, 6-10y

Multinutrient capsule (containing 0.09g DHA + 0.02g EPA/d) for 12 months

Improved DHA/EPA status, verbal learning and memory in intervention group.

N=362, 7-9y

DHA (0.6g/d) for 16 wks.

Better reading in children with poor reading performance â&#x2030;¤20th centile in intervention group.

N=196, 13-16y

DHA/EPA (0.12/0.16g/d) + multivitamin daily for 12 wks.

Improvement in Connersâ&#x20AC;&#x2122; disruptive behaviour scale in intervention group, whereas placebo group worsened.

N=450, 8-10y

DHA/EPA (0.23g/d) for 4 months then all children received active intervention for 8 wks.

Decreased inattention and improved behaviour in intervention group. No differences in IQ or school performance.

N=175, 4y

DHA (0.4g/d) for 16 wks.

Improved performance in listening comprehension and vocabulary acquisition tests in group with better DHA status. No differences in cognitive function overall.

N=321, 6-11y with iron deficiency and low LCn3PUFA status

Daily iron (50mg/d) plus DHA/EPA (0.42/0.08g/d) for 4 wks vs iron only or DHA/EPA only.

No differences in cognitive function for DHA/EPA alone but some improvement for iron supplementation.

N=90, 10-12y

DHA (0.4g vs 1.0g/d) for 8 wks.

No differences in cognitive function.

Key: DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; GLA, gamma linoleic acid; d, day; wks, weeks; y, years; N, sample size; IQ, intelligence quotient.

Reasons for inconsistency in the overall findings include differences in dosage (0.1 to 1.0g daily), duration of study (four weeks to four years) and a lack of information about baseline fatty acid status in many of the studies. In the two studies where no benefit was seen, the duration was four or eight weeks, which is likely to be too short given that animal studies suggest that two to three months of supplementation are required for LCn3PUFA to be incorporated into brain tissue.9 Another issue affecting most of the studies is the optimal window of opportunity for LCn3PUFA supplementation, which may be prenatally, or in the early months of life according 42

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to animal models and intervention studies in pregnancy.6 Looking at the LCn3PUFA dosage given in successful studies (0.2-0.4g daily) and relating this to the richest natural food source, i.e. oily fish, a considerable intake would be required each week. Figure 1 illustrates this using nutritional data on fish19 and shows that, each week, children would need to eat 150g of salmon, mackerel or sardines, or more than 250g fresh tuna to achieve optimal LCn3PUFA intakes. Other foods do contain LCn3PUFA, e.g. eggs, meat and fortified foods, but the amounts are very low. However, fish oil supplements are an excellent source and typically contain 0.1-0.5g LCn3PUFA per dose.

Achieving 0.2-0.4g/d LCn3PUFA would be difficult for children given that current intakes, estimated from the National Diet and Nutrition Survey, are 0.11 g in 4-10 year olds and 0.12g in 11-18 year olds.20 This is mainly because so few children (6-11%) eat oily fish on a regular basis.18 There is no official advice on fish or LCn3PUFA intakes in children, simply a general population guideline to consume two portions of fish weekly, including one of oily fish. This would be expected to provide the equivalent of 0.45g/day LCn3PUFA (3.0g weekly).21 The recommended portion size of 140g may be too large for younger children, so a practical consideration would be to encourage even a small portion of oily fish weekly then augment this with a daily fish oil supplement. The benefit would be greater in children who do not consume any oily fish as intakes could be increased five-fold with supplementation.5 CONSUMER SURVEY

Parentsâ&#x20AC;&#x2122; views on learning and the potential effect of LCn3PUFA were investigated in an online survey of 1,000 UK parents of children aged four to 16 years attending mainstream schools. The survey was commissioned by Equazen and conducted by independent pollsters, OnePoll. Just over a third of parents were worried about

their childrenâ&#x20AC;&#x2122;s reading ability, yet the average time that children spent reading for pleasure each week was 2.4 hours. In contrast, children spent more than three hours a day on average (21 hours a week) watching TV and playing computer games. There was good knowledge about the best source of LCn3PUFA in the diet, with 74% of parents identifying oily fish, but some confusion about other foods since chicken, wholegrains, fruits, vegetables and dairy products were also mentioned. This probably reflects a lack of understanding about the difference between vegetable sources of omega-3s, i.e. alphalinolenic acid, and fish oil sources, i.e. EPA and DHA, for which there is much better evidence of benefit. Around a quarter of parents gave their children a supplement, typically a multivitamin, but this would not provide EPA, DHA and other fatty acids which support brain health. Indeed, most parents (64%) either felt that their children were not getting enough LCn3PUFA or were unsure about it. This suggests that parents are struggling to determine how much LCn3PUFA their children typically have in their diets and how this relates to recommendations. As more than 40% of parents were getting their health information online, there is an

Figure 1: Amount of oily fish (fresh and frozen) required weekly by children to achieve optimal intakes of LCn3PUFA for school performance

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NUTRITIONAL SUPPLEMENTS

opportunity for healthcare professionals to engage more on this issue using the internet. Another key source of health information cited by parents was GPs, although it is unclear how much knowledge they would have about LCn3PUFA sources and the role of supplements. CONCLUSIONS

The evidence from randomised trials suggests that educational performance in children could benefit from increased LCn3PUFA in the diet, especially if children typically have a low LCn3PUFA status, or are underperforming in reading. Further research needs to be conducted, with consistent durations, dose, baseline levels and participant selection, to ensure better

comparisons across studies. The optimal ratio between DHA and EPA, as well as a role for other fatty acids, such as gamma linolenic acid, should also be considered in future trials. For example, early work on an EPA/DHA/GLA formulation has demonstrated a positive impact on writing and spelling (Equazen, in press). Increasing oily fish consumption is the best food-based method for improving LCn3PUFA status, but current uptake of official advice on fish is very low in children. Until this can be resolved, a daily fish oil supplement is a simple and useful way for parents to help their children meet recommended levels of LCn3PUFA and support their educational performance.

References 1 Fernstrom JD (2000). Can nutrient supplements modify brain function? Am J Clin Nutr 71: 1669S-73S 2 McNamara RK et al (2006). Role of omega-3 fatty acids in brain development and function: potential implications for the pathogenesis and prevention of psychopathology. Prostaglandins Leukot Essent Fatty Acids 75: 329-349 3 O’Brien JS and Sampson EL (1965). Lipid composition of the normal human brain: grey matter, white matter, and myelin. Journal of Lipid Research 6: 537-544 4 Martins JG (2009). EPA but not DHA appears to be responsible for the efficacy of omega-3 long chain polyunsaturated fatty acids supplementation in depression: Evidence from a meta-analysis of randomised controlled trials. J Am Coll Nutr 28: 525-542 5 Calder PC and Yaqoob P (2010). Understanding omega-3 polyunsaturated fatty acids. Postgraduate Medicine 12: 148-157 6 Kuratko CN et al (2013). The relationship of docosahexaenoic acid (DHA) with learning and behaviour in healthy children: A review. Nutrients 5: 2777-2810 7 Ruxton C and Derbyshire E (2013). Fatty acids in the management of ADHD. Complete Nutrition 13: 85-87 8 Kirby A et al (2010). Children’s learning and behaviour and the association with cheek cell polyunsaturated fatty acid levels. Res Dev Disabil 31: 731-42 9 Frensham LJ et al (2012). Influences of micronutrient and omega-3 fatty acid supplementation on cognition, learning, and behaviour: methodological considerations and implications for children and adolescents in developed societies. Nutr Rev 70: 594-610 10 Brew BK et al (2015). Omega-3 supplementation during the first five years of life and later academic performance: a randomised controlled trial. Eur J Clin Nutr 69: 419-24 11 Parletta N et al (2013). Effects of fish oil supplementation on learning and behaviour of children from Australian Indigenous remote community schools: a randomised controlled trial. Prostaglandins Leukot Essent Fatty Acids 89: 71-9 12 Osendarp S, Baghurst KI, Bryan J et al (2007). Effect of a 12-month micronutrient intervention on learning and memory in well-nourished and marginally nourished school-aged children, two parallel, randomised, placebo-controlled studies in Australia and Indonesia. Am J Clin Nutr 86: 1082-1093 13 Richardson AJ et al (2012). Docosahexaenoic acid for reading, cognition and behaviour in children aged 7-9 years: a randomised, controlled trial (the DOLAB Study). PLoS One 7: e43909 14 Tammam JD et al (2016). A randomised double-blind placebo-controlled trial investigating the behavioural effects of vitamin, mineral and n-3 fatty acid supplementation in typically developing adolescent schoolchildren. Br J Nutr 115: 361-73 15 Kirby A et al (2010). A double-blind, placebo-controlled study investigating the effects of omega-3 supplementation in children aged 8-10 years from a mainstream school population. Res Dev Disabil 31: 718-30 16 Ryan AS and Nelson EB (2008). Assessing the effect of docosahexaenoic acid on cognitive functions in healthy, preschool children: a randomised, placebo controlled, double-blind study. Clin Pediatr 47: 355-362 17 Baumgartner J et al (2012). Effects of iron and n-3 fatty acid supplementation, alone and in combination, on cognition in school children: a randomised, doubleblind, placebo-controlled intervention in South Africa. Am J Clin Nutr 96: 1327-38 18 Kennedy DO et al (2009). Cognitive and mood effects of eight weeks’ supplementation with 400mg or 1000mg of the omega-3 essential fatty acid docosahexaenoic acid (DHA) in healthy children aged 10-12 years. Nutr Neurosci 12: 48-56 19 Ruxton CHS (2011). The benefits of fish consumption. Nutr Bull 36: 6-19 20 Gibbs R (2012). Personal communication. Figures calculated from the National Diet and Nutrition Survey rolling programme 2008-11 21 Scientific Advisory Committee on Nutrition/Committee on Toxicology (2004). Advice on fish consumption: benefits and risks. TSO: London

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COMMUNITY

PRESCRIBING ORAL NUTRITIONAL IN ASSOCIATION WITH SUPPLEMENTS Declan O’Brien, Director General of the BSNA

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

The provision of healthy, nutritious food should always be the first choice for managing malnutrition. Oral Nutritional Supplements (ONS) can complement, or wholly replace, a normal diet to provide patients with the essential nutrients they need when food alone is insufficient to meet their daily nutritional requirements. Facing huge pressure to cut costs where they can, some clinical commissioning groups (CCGs) have limited, or restricted, the prescription of ONS. One CCG has severely restricted the prescription of ONS in care and nursing homes; another appears to view the use of ONS as a case of last resort and only when all other avenues have been exhausted. These policies are misguided and both fly in the face of the existing evidence and fail to consider long-term outcomes. The Managing Adult Malnutrition in the Community pathway1 clearly indicates that ONS should be used in combination with food as part of the management of malnutrition; this is also referenced in the recently launched NHS England Commissioning Excellent Nutrition and Hydration (2015-2018) document.2 ONS support positive health outcomes and reduce costs to the NHS. ESSENTIAL MEDICAL MANAGEMENT

Patients requiring ONS range from those who are critically ill and those with inherited genetic disorders, to those with chronic illnesses. These may include cancer, kidney failure, cystic fibrosis, diabetes, dysphagia, loss of muscle mass and respiratory disease. In addition, specialist products may be required for people with inborn errors of metabolism, problems with absorption of normal foods, for enteral nutrition administered via nasogastric tube (NGT), or percutaneous endoscopic gastrostomy (PEG).

ONS can be an essential part of medical management and may be required either for life or for short periods of time, depending on a patient’s clinical circumstances. In these cases, they guard against malnutrition until a normal diet can be resumed. They can be a lifeline in the community, where round-the-clock care may not be available. However, recent statements from some CCGs have seemed to suggest that the provision of fortified food is a like-for-like replacement for ONS. This approach is over-simplified, does not adequately take into account a patient’s clinical requirements, or the clinical assessment made by the healthcare professional. As such, it results in inequity of care for patients whose health outcomes may, as a result, become determined by where they live. The better approach would be to ensure that patients receive appropriate nutritional support, based on their particular circumstances, wherever they are. This would comply both with existing best practice national guidelines and the guiding principle in CCGs’ own constitutions: ‘access to services based on clinical need’. NICE Clinical Guideline 32 states: “Oral nutrition support includes any of the following methods to improve nutritional intake: fortified food with protein, carbohydrate and/or fat, plus minerals and vitamins; snacks; oral nutritional supplements; altered meal patterns; the provision of dietary advice.”3

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COMMUNITY It also states: “Healthcare professionals should ensure that the total nutrient intake of people prescribed nutrition support accounts for energy, protein, fluid, electrolyte, mineral, micronutrients and fibre.”4 The NICE Quality Standard on Nutrition Support in Adults (QS24),5 recognises that ONS are a clinically effective way to manage diseaserelated malnutrition when food alone, however nutritious, is not sufficient to meet a person’s dietary needs: “It is important that nutrition support goes beyond just providing sufficient calories and looks to provide all the relevant nutrients that should be contained in a nutritionally complete diet. A management care plan aims to provide this and identifies condition specific circumstances and associated needs linked to nutrition support requirements.” NICE QS24 also advises that care should be taken when providing food fortification alone, which tends to supplement energy and/or protein without necessarily providing sufficient or adequate micronutrient levels. SAVING MONEY AND REDUCING WASTE

When CCGs are looking to reduce their overall expenditure on prescription costs, it is important to look at the burden of malnutrition in the local health economy in terms of hospital admissions and readmissions and to ensure that the nutritional needs of those patients who are malnourished, or at risk of malnutrition, are managed appropriately. We believe that nutritional support, including ONS, plays a valid and very important role in patient care and has significant clinical and health economic benefits. However, patients should only be prescribed ONS when they cannot meet their daily nutritional requirements from food alone, or are at risk of malnutrition due to a disease, disorder, medical condition or surgical intervention. For example, patients recovering from surgery, those with cancer or those who have had a stroke may find it difficult to eat because they cannot swallow or digest food properly, or because they have lost their appetite. If this is the case, they may need ONS to support their recovery and avoid becoming malnourished. Patients who have been clinically screened, and whose management plans recommend or require the use of ONS, should have equity of access to available care.

We understand that some CCGs have received anecdotal evidence that ONS are overprescribed, thus becoming out of date and then thrown away. We would be concerned if any commissioning decisions to restrict the use of ONS per se were being made on the basis of anecdotal evidence of over-supply of product in some cases. We do, however, share CCGs’ concerns about waste and would always recommend that ONS is prescribed only when needed and combined with regular monitoring and review of patients’ needs by a healthcare professional as outlined in NICE CG32, NICE QS24 and the Managing Adult Malnutrition in the Community Pathway. It is important to note that if hospitals and care homes fully implemented NICE CG32 (screening those who may be at risk of malnutrition, having the right care pathways in place based on a patient’s malnutrition risk score, conducting regular monitoring and review), they would ensure that only those who need ONS support actually receive it. Similar considerations should also apply to patients who receive ONS in the community. The health and social care costs associated with malnutrition are estimated to be £19.6 billion per year in England alone,6 amounting to more than 15% of the total public expenditure on health and social care.7 About half of this expenditure is accounted for by older people (>65 years) and the other half is attributed to younger adults and children. In its guidance on cost savings,8 NICE recognises that significant savings can be achieved relatively quickly through the provision of good nutritional support. Ensuring that patients who are malnourished, or who are at risk of malnutrition, are treated appropriately and in a timely manner avoids secondary treatment and costs, as well as higher re-admission rates. Other studies also highlight the cost-effectiveness of ONS in treating malnutrition.9,10,11 A systematic review of the cost and cost effectiveness of using standard ONS in community and care home settings found that cost-savings were demonstrated for short-term use of ONS (up to three months), with a median cost saving www.NHDmag.com August / September 2016 - Issue 117

COMMUNITY

Restrictions of ONS are of significant concern and are likely to affect patients’ long-term health outcomes.

of 9.2% (P<0.01). Studies investigating cost savings for the use of ONS for three months or more found a median cost saving of around 5%.10,12 Furthermore, a systematic review demonstrates that there is very little evidence of efficacy of treating malnutrition with foodbased strategies alone compared to the use of ONS.13 A number of favourable clinical outcomes were also associated with use of ONS, including improved quality of life, reduced minor postoperative complications, reduced infections and reduced falls.14 The recent British Association for Parenteral and Enteral Nutrition (BAPEN) and the National Institute for Health Research Southampton Biomedical Research Centre (NIHR) report7 stated that it costs three times more to treat or manage a malnourished patient compared to one without malnutrition, equating to £5,329 per patient. The single most important variable affecting the net cost balance was the cost saving due to the effect of ONS in reducing the length of hospital stay. In short, reduced use of healthcare resources due to ONS use could save the NHS £101.8 million every year.7 Moreover, implementing

NICE CG32/QS24 in 85% of those at medium and high risk of malnutrition would lead to a net saving of £172.2 to £229.2 million, which equates to between £324,800 and £432,300 per 100,000 head of population.7 CONCLUSION

Restrictions of ONS are of significant concern and are likely to affect patients’ long-term health outcomes. Although CCGs are under increasing pressure to cut costs, a blanket approach using first-line measures is unlikely to be appropriate for all patients in all circumstances. Patients with co-morbidities, in particular, most stand to benefit from nutritional advice that is uniquely tailored to their own clinical circumstances. We believe that ONS should be available on prescription to all patients who need them and recognised as an integral part of the management of conditions which require nutritional support. Dietitians are well placed to evaluate when, and for how long, patients require ONS and will, we hope, speak up for patient-centred care. For more information and to download a copy of our information sheet on the value of FSMPs see: www.bsna.co.uk/categories/medical_foods/

British Specialist Nutrition Association (BSNA)

BSNA is the trade association representing the manufacturers of products designed to meet individuals’ particular nutritional needs; these include specialist products for infants and young children (including infant formula, follow-on formula and complementary weaning foods) and medical nutrition products for diagnosed disorders and medical conditions, including parenteral nutrition and gluten-free foods. www.bsna.co.uk.

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SKILLS & LEARNING

FREELANCE PRACTICE: MANAGING CANCER CARE CLIENTS 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.

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

There is no doubt in my mind that freelance practice is a wonderful place to be for a dietitian. It comes with a long list of benefits such as variety, being able to manage your own appointment books, flexible working hours, strong and supportive freelance networks and being able to utilise a range of different practice models. Freelance does, however, come with special concerns and particular issues around which the registered dietitian needs to be mindful. Opening my daily emails brings a raft of different requests: weight management, women’s ‘issues’, IBS, allergies and intolerances, inflammatory conditions and more. Then, there it is: the cancer question arises. In my practice, I receive at least three emails a month from prospective clients or their relatives asking for help with a cancer diagnosis. The emails are usually asking for help ‘fighting the cancer’. My emails this month have included: “Hi, my Dad has been diagnosed with multiple myeloma; looking for a diet not to feed the cancer.” “I have stage 3 breast cancer and am going through my third chemo course. I would like some help with some meal plans, getting my energy back and fighting the cancer. I eat a raw diet.” “You are my last hope; my husband has a rare brain cancer and needs a ketogenic diet. Are you familiar with using cannabis oil therapy?” My heart sinks when I read emails like this. As a dietitian, I want to help. That’s what we do. There is nothing more rewarding that being able to help someone feel better, or to manage their condition with dietary changes. There is nothing better than seeing that your clients have gained from your support and guidance. Then there is the fact that, when it comes down to it, freelance practice is a business.

The temptation in freelance is to ‘take everything’. The temptation is to assume that your knowledge base is so broad that you can advise on any condition that comes your way. When dealing with freelance clients, paying clients, there is an emphasis on client choice. The issue of payment potentially adds to dilemma in practice. Questions arise for freelance dietitians such as, “Do I give them what they want?” and “If I say no, then where will the client end up getting their advice? Will it be safe?” So, what is the problem? The issue with taking on and assisting cancer care clients in freelance practice is around professional ethics and the very real issue of protecting yourself legally. In freelance practice, ethics are more important than ever. You are still bound by the HCPC standards of proficiency and, potentially, are at greater risk of exposure to unsafe practice allegations due to the single practitioner care model. Managing cancer care clients can put a practitioner at a risk due to the issues arising from the emotions and fears that may come with cancer care clients and their families. These include hope and desperation, unproven diet therapies being touted as miracle cures and the phases that come with the grieving process. To demonstrate context, many years ago, whilst working for the NHS, I witnessed a series of complaints against a well-meaning dietitian who offered to remove the enteral feeding equipment from the home of a gentleman who had recently passed away. The relatives saw

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SKILLS & LEARNING this as ‘too soon’ and as somewhat mercenary, so complaints ensued. The dietitian in question had just thought it to be a gesture of kindness. It is difficult to determine how families will react. The complaints were dealt with sensitively, aided by the support of a team. In freelance practice, there is generally no such team. So how do freelance dietitians combine accepting referrals to maintain an income, managing to practice within ethical and evidence based guidelines, keeping the client happy and working to the dietetics care model, whilst protecting themselves and the profession? TIPS FOR ACCEPTING CLIENTS

Communication and consent Self- referrals are acceptable in freelance practice. This is fine for many situations but is not advised for cancer care clients. In cases of a cancer diagnosis, before even accepting the client, it is necessary to contact the potential client’s GP and/or oncology team in order to confirm the diagnosis and treatment plan. This should be done with the consent of the client. It is also important to include contacting the local NHS service Dietetic team, if there has been some involvement, for a handover of care. During the course of the client’s care, he or she may be likely to spend some time as an inpatient. If this is the case, it is important to maintain communication with the dietitians in the NHS service and to work with mutual respect and goals of care. There may be miscommunications from the client or family, regarding treatment goals, which may lead to questions about your care. It is sensible, therefore, to ensure that your peers are in no doubt that you are practicing to standard. If, after establishing the diagnosis and details of care, a freelance dietitian does decide to accept a client for cancer care, then there must be written consent for treatment and for information sharing/confidentiality. Know your unproven diet theories for cancer care There are so many unproven dietary therapies for managing and ‘curing’ cancer. ‘Starving the cancer’ by ridding sugar from the diet, alkaline diets, Gerson therapy and ‘raw’ food diets, juicing, ketogenic diets, paleo and vegan diets are just a few. It is important to have a good knowledge of 50

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the current dietary therapies and those present on the internet and in the media and to be aware of the evidence around each of the same. When being asked to assist with an unproven dietary therapy, the freelance dietitian should be in a position to discuss the evidence, possible benefits and dangers of proceeding with such therapies. Be able to stand your ground and be involved in frank and honest discussions about what you can offer. Unproven therapies should not be commenced on recommendation by the dietitian. Maintain your knowledge base and work within the dietetic care process When accepting a client in the case of cancer care, the following points are important: • A current knowledge of the evidence base and up-to-date guidelines for cancer management is essential: NICE guidelines, oncology SIG documents, PEN evidence based practice points. • Maintain a robust CPD record. • Always use the dietetic care process. • Keep within the scope of practice. Take care in discussions around supplements and herbal therapies as these can be taken as tacit approval by clients. • Outcome measures - keep them realistic, manageable and measurable. Establish these with the client to ensure that there is a mutual understanding of the goals of care. • Use approved and evidence-based resources and give goals of care in writing. It is advisable to use permitted resources produced by other reputable organisations which are known to have accepted and evidence-based materials. Document, document, document The key to documentation is to leave absolutely no doubt that the client was continually assessed, monitored and treated by a competent dietitian. Documentation helps prove that the dietetic care process has been followed correctly, that the dietitian has justified their clinical decisions based on the evidence base, has worked within their scope of practice and has provided the expected standard of care to the client. Accurate and comprehensive documentation honours the ethical concepts on which best

practice is based and demonstrates the basis for professional and clinical decisions. This includes records or care and letters to the client’s GP and/or oncologist, outlining a summary of each consultation. It may even be useful to use a client/practitioner contract, which outlines care expectations, goals and treatments. Professional/peer supervision The most mentioned concern for freelance dietitians in clinical practice is usually the isolation that can come with the choice to ‘go it alone’. Professional supervision and establishing a mentoring relationship with another dietitian is advised. This is particularly important when faced with accepting cancer care clients. Clinical supervision allows the freelance dietitian to discuss currency, cases and ethical dilemmas and, when documented correctly, also works to provide further evidence of good practice if unsafe practice allegations are raised. On reading the HCPC disciplinary hearing summaries, I was alarmed to see that there had been discussions, in one case, around ‘the dietitian’s word’ vs ‘the client’s word’, despite documentation being maintained. Clinical and peer supervision is one way that a freelance dietitian can have the backing of the ‘team’ with additional and ‘cross-check’ documentation and, therefore, to not be left unsupported should cases be brought against them. Maintain your insurance and memberships Professional indemnity insurance provides cover for claims brought against the policyholder due to their professional negligence. By the end of this year, the government will introduce legislation which requires registrants to have professional indemnity insurance as a condition of their registration with the HCPC. Ensuring current membership with the BDA is crucial for dietitians in freelance practice, as this, along with other benefits, ensures that professional indemnity arrangements are in place. If a dietitian chooses not to maintain membership with the BDA, they must arrange their insurance independently and be able to declare currency of policy when renewing HCPC registration. It is important to note that, in the event of a claim, the onus is on the dietitian to demonstrate

that they have worked within the bounds of safe practice. Know your limits/know when to say no Even if a freelance dietitian has a reasonable amount of experience working in oncology and has all of the safe practice structures in place, it is important to consider whether or not accepting a cancer care client falls within their abilities, or, indeed, if accepting the client poses a professional risk. Of course, not all cancer care clients will come with the danger of unsafe practice allegations and ethical challenges, but, often, freelance Dietitians are seen as a ‘last port of call’ for clients after being through the public health services. Very often, therefore, these clients do come with potential agendas which cannot be met by the dietitian. Freelance dietitians, often generalist practitioners, can be in danger of using the ‘take everything’ approach. The freelance dietitian needs to know their limits and to know when to refer onto more specialist practitioners. Consideration needs to be made too, as to whether the client can best be supported within a team, rather than working with a dietitian in a single practitioner model. CONCLUSION

Managing a client who has cancer can be challenging, but also incredibly rewarding. There is no reason why dietitians in freelance practice should ‘shy away’ from accepting these clients, but they should be aware of the potential ethical issues that can come alongside. In most cases, following the dietetic care process and evidence-based guidelines can help these clients with their diagnosis and disease progression, as well as complications, side effects of treatment and the disease and changing physical capacity and quality of life. In some instances, the dietitian may accept a cancer care client who has chosen to go down the path of an unproven dietary therapy. This can be done with special care and support and, without endorsing the therapy, with an effort to protect the client by ensuring that an adequate diet is maintained and no harm is done. The most important thing is that both the client and the freelance dietitian should be protected. www.NHDmag.com August / September 2016 - Issue 117

ONLINE RESOURCES

WEB WATCH Useful information, research and updates. Visit www.NHDmag.com for full listings. NICE GUIDELINES/STANDARDS UPDATES NICE QUALITY STANDARD [QS125] DIABETES IN CHILDREN AND YOUNG PEOPLE Published July 2016 This quality standard covers the diagnosis and management of Type 1 and Type 2 diabetes in children and young people aged under 18. This quality standard will not cover care for children and young people with other forms of diabetes mellitus (such as monogenic diabetes or cystic fibrosis-related diabetes). Management of diabetes in women aged under 18 who are planning pregnancy or already pregnant is covered by the NICE guideline and quality standard on diabetes in pregnancy. www.nice. org.uk/guidance/QS125 NICE GUIDELINE [NG28] TYPE 2 DIABETES IN ADULTS: MANAGEMENT Updated July 2016. This guideline covers the care and management of Type 2 diabetes in adults (aged 18 and over). It focuses on patient education, dietary advice, managing cardiovascular risk, managing blood glucose levels, and identifying and managing long-term complications.

In July 2016, recommendation 1.7.17 has been reworded to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen. www.nice.org.uk/ guidance/NG28 NICE GUIDELINE [NG17] TYPE 1 DIABETES IN ADULTS: DIAGNOSIS AND MANAGEMENT Updated July 2016 This guideline covers the care and treatment of adults (aged 18 and over) with Type 1 diabetes and updates and replaces the sections for adults in NICE guideline CG15. In July 2016, recommendation 1.15.1 has been reworded to clarify the role of GPs in referring people for eye screening and also to add information on when this should happen. www. nice.org.uk/guidance/NG17 NICE GUIDELINE [CG181] CARDIOVASCULAR DISEASE: RISK ASSESSMENT AND REDUCTION, INCLUDING LIPID MODIFICATION Updated July 2016 This guideline covers the assessment and care of adults who are at risk of

or who have cardiovascular disease (CVD), such as heart disease and stroke. It aims to help healthcare professionals identify people who are at risk of cardiovascular problems. Including people with Type 1 or Type 2 diabetes, or chronic kidney disease. It describes the lifestyle changes people can make and how statins can be used to reduce their risk. In July 2016, recommendation 1.2.2 was amended to clarify the advice on saturated and monounsaturated fat. www. nice.org.uk/guidance/cg181 NICE GUIDELINE [NG49] NONALCOHOLIC FATTY LIVER DISEASE (NAFLD): ASSESSMENT AND MANAGEMENT Published July 2016 This guideline covers how to identify the adults, young people and children with nonalcoholic fatty liver disease (NAFLD) who have advanced liver fibrosis and are most at risk of further complications. It outlines the lifestyle changes and pharmacological treatments that can manage NAFLD and advanced liver fibrosis. www.nice. org.uk/guidance/ng49

NHS CHOICES: ADULT PHYSICAL ACTIVITY Itâ&#x20AC;&#x2122;s an Olympic year and physical activity is definitely a talking point for many, but some patient may need some inspiration and guidance to kick start their lifestyle changes. NHS Choices offers a great page for discussing the right type of physical activity for patients of all weights and sizes. Patients can assess their current PAL and discover which types of activity suit them best. Physical activity guidelines for adults are discusses and downloadable fact sheets are available. www.nhs.uk/Livewell/fitness/Pages/physical-activity-guidelines-foradults.aspx

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DEPARTMENT OF HEALTH NUTRITIONAL AND HEALTH CLAIMS LEGISLATION BULLETINS 2016 Published 8th July 2016 The latest bulletins from the Department of Health on EU legislation on nutrition and health claims about food is available at www.gov.uk/government/publications/ nutritional-and-health-claims-legislationbulletins-2016. The June 2016 bulletin contains updates on caffeine claims, the use of the term ‘probiotic’ and discussion on a health claim related to glycaemic carbohydrates and cognitive function. HEALTHCARE UK OVERVIEW AND ANNUAL REVIEW APRIL 2015 TO MARCH 2016 Published 7th July 2016 This document sets out Healthcare UK’s activities and performance for the period 1st April 2015 to 31st March 2016. The full review is available at https://www.gov. uk/government/publications/healthcareuk-overview-and-annual-review-april2015-to-march-2016 CHOICE IN END OF LIFE CARE: GOVERNMENT RESPONSE Published 5th July 2016 This document is the government’s response to the independent review of choice in end of life care. The report details the six commitments that the government has made to the public to end variation in end of life care across the health system by 2020. These are: • Honest discussions between care professionals and dying people • Dying people making informed choices about their care • Personalised care plans for all • The discussion of personalised care plans with care professionals • The involvement of family and carers in dying people’s care • A main contact so dying people and their families know who to contact at any time www.gov.uk/government/publications/choicein-end-of-life-care-government-response

NEW RESOURCE: MANAGING MALNUTRITION IN COPD A new practical resource, Managing Malnutrition in COPD, has been launched to assist healthcare professionals in identifying and managing people with COPD who are at risk of disease-related malnutrition. The guidance includes a pathway for the appropriate use of Oral Nutritional Supplements (ONS) to support community healthcare professionals and has been developed by a multi-professional panel with an interest in malnutrition in COPD and is endorsed by 10 key professional and patient organisations. Three complementary colour-coded patient leaflets (green - low risk, yellow - medium risk and red - high risk) containing dietary advice, advice on eating and physical activity, plus tips on coping with common symptoms, including dry mouth, taste changes and shortness of breath, have also been developed. In addition, the red (high risk) leaflet includes advice for patients on incorporating ONS into their diet. Free copies of the guidance and supporting materials can be downloaded for free at: www.malnutritionpathway.co.uk/copd/

DIABETES UK RESOURCES: ENJOY FOOD The Diabetes UK website offers a wealth of medical, nutritional and practical information for patients and healthcare professionals. It’s an ideal place to find sound information about all things diabetes. Each month the site features a selection of articles about life with diabetes, treatment and diet tips under the ‘Enjoy Food’ section. This section delivers recipes, healthy eating tips, ideas, and inspiration to enjoy food despite having Diabetes. This month’s features include managing carb counting, healthy picnic ideas and how to deal with sugar cravings. There is also an opportunity to interact with the ‘Enjoy food’ team where visitors can email ideas and feedback to enjoyfood@diabetes.org.uk. It’s worth a look at www.diabetes.org.uk/ Guide-to-diabetes/Enjoy-food/Whats-new-thismonth-/ www.NHDmag.com August / September 2016 - Issue 117

DATES FOR YOUR DIARY UNIVERSITY OF NOTTINGHAM SCHOOL OF BIOSCIENCES

Modules for Dietitians and other Healthcare Professionals • Obesity Management (D24BD3) 6th & 7th October, 9th & 12th December • Gastroenterology (D24GE1) 13th & 14th October, 14th & 15th December

• IBS and a low FODMAP diet single study day 14th October For further details please contact Susan Lewis via email: Susan.Lewis@nottingham.ac.uk. Alternatively, check out the University website at http://www.nottingham.ac.uk/biosciences and click on ‘Study with us’ and then ‘short courses’ which will take you to ‘for practising dietitians’.

17th International Congress on Dietetics - ICDA 7th-10th September - Granada, Spain www.icdgranada2016.com/index.asp Introduction to Parenteral Nutrition BDA Trainer - Amelia Jukes 8th September - London Road Community Hospital, Derby www.ncore.org.uk Recipe Analysis: Maximising Accuracy Nutrition and Wellbeing 9th September www.susanchurchnutrition.co.uk/recipe-analysis-training/ Food labelling regulation - implementation, impact and the future for UK policy 13th September - London www.westminsterforumprojects.co.uk/forums/event. php?eid=1271&t=16940

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

SENIOR COMMUNITY DIETITIAN - ENTERAL FEEDING PROJECT - ABL HEALTH Salary: Up to £32,000 (dependent on experience) To provide senior dietetic support within a new community nutrition support service across Manchester. In line with ABL’s holistic approach to healthcare, we require a dietitian who is experienced in community home enteral feeding (HEF) and nutrition support with clients in their homes and/or in clinics. The post holder will plan and prioritise their own clinical caseload and liaise with other services where required (including social services, SALT, stroke, physio, occupational therapists). We welcome applications from dietitians with one to two years’ experience plus flexible working and job share available. Training and supervision. For details visit: www.ablhealth.co.uk/vacancies/manchester-seniorcommunity-dietitian/ Closing date: 31st August 2016

COMMUNITY DIETITIAN - HOME ENTERAL FEEDING - MANCHESTER - ABL HEALTH Salary: Up to £26,000 (dependent on experience) To provide dietetic support within a new community nutrition support service across Manchester. In line with ABL’s holistic approach to healthcare, we require a dietitian to provide dietetic nutrition support to clients in their homes, care homes and clinics. The post holder will plan and prioritise their own clinical caseload and liaise with other services where required (including social services, SALT, stroke, physio, occupational therapists). We welcome applications from new graduates. Flexible working and job share available, plus training and supervision. For full details visit: www.ablhealth. co.uk/vacancies/manchester-community-dietitian/ Closing date: 31st August 2016

dieteticJOBS.co.uk To place an ad or discuss your requirements please call

0845 450 2125 (local rate) 54

www.NHDmag.com August / September 2016 - Issue 117

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.

Well this month’s Final Helping has undergone a last-minute change. Type 1 diabetes has to be the main topic. This is as a result of Theresa May becoming Prime Minister of the United Kingdom. She was diagnosed three years ago and now we have a further high profile example, particularly to young people with this condition, of what can be achieved and undertaken whilst managing their chosen path in life. Whatever political views you may have, Theresa May should be an inspiration to many. In the past, I have followed the way that two top sportsmen, both with Type 1 diabetes, have performed. Sir Steve Redgrave, a British rower and winner of gold medals at five consecutive Olympic Games from 1984 to 2000 and Gary Mabbutt, England International footballer who made 477 appearances for Tottenham Hotspur, have both reached the pinnacle in their respective sporting pursuits. Now we are in the position of viewing probably the most high profile person in the country carrying out her extremely demanding political role and “getting on with it”. When I tuned in to Mrs May’s first ‘Prime Minister’s Question Time’ from the House of Commons, the issue was indeed raised. Jamie Reed, Labour MP for Copeland stated, “As a Type 1 diabetic and as a father and an uncle to children with Type 1 diabetes, on behalf of five hundred thousand people, thirty thousand of them children in this country, can I thank the prime Minister for the example she has shown to those

people in demonstrating without doubt that it doesn’t hold us back in any way whatsoever.” Mrs May replied, “There are many youngsters out there, from tiny tots to teenagers, living with Type 1 diabetes and I think it’s important that we give the message to them that their future is not limited, they can do whatever they want.” By coincidence a further example of this was brought to my attention by my next-door-neighbour a few days earlier. He is a teacher with Type 1 diabetes and is participating in a study whereby you can test your blood sugar using a small sensor that is placed on the back of your upper arm with an applicator and automatically captures glucose readings day and night. He showed me and in literally one second he had a glucose reading. It even has an eight-hour glucose history, is water resistant and can be taken through clothing. The feedback from users has seemingly been excellent, so further supporting them in managing their condition and their lives. For me, I also only just found out that my iPhone also measures how many steps I take each day via the ‘Health App’, so excuse me if this is not new news to you all. I’m off for a walk…

www.NHDmag.com August / September 2016 - Issue 117

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NHDmag.com August / September 2016: Issue 117

SPORTS NUTRITION CASE STUDY

by Helen Phadnis

FUTURE FOODS FROM EDIBLE INSECTS GIVE ME ENERGY... Ursula Arens takes a look at the energy drinks market A DAY IN THE LIFE OF... a Meals on Wheels Nutritionist

NHD EXTRA: PUBLIC HEALTH

GIVE ME ENERGY . . . Review by Ursula Arens Writer; Nutrition & Dietetics

While sweet and sugary drinks face all-round critique from dietitians, it is a mystery that the sector of self-proclaimed ‘energy’ drinks seems to be thriving. Correction: not ‘seems to be’ - ‘is’…

Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula guides the NHD features agenda as well as contributing features and reviews

The link to virile masculinity and gungho disruptiveness seems to transcend any concerns over bad teeth and obesity. In debates about energy drinks amongst politicians and regulators, the sugar content of energy drinks is low down over the other contentious ingredients of too much caffeine and mysterious herbals. The sector is booming. More than half of the global market is dominated by two brands: Red Bull and Monster. According to market researcher Euromonitor International, global sales of energy drinks in 2015 were more than €38 billion. More than one third of the global market is the US. China had lower sales than Western Europe in 2015 (€6 vs €7 billion), but is the fastest growing market, predicted to double by 2020 and overtake the US by 2025. Interestingly, two of the top three brands are privately owned: Dietrich Mateschitz owns Red Bull and Russ Weiner owns Rockstar - perhaps they swim in the stuff. The number two brand, Monster, is coowned by the Coca Cola Company.

The success of energy drinks must be due to the many meanings of the word ‘energy’. Dietitians need no review of the meaning of food energy. However, the consumer meaning drives the communication of these products: take your pick of the string of synonyms: vigor/forceful effect/power/capacity to do work/ oomph/ get-up-and-go/ drive/vim - and many other terms. Clearly, a drink that delivers these traits is valued, rather than the dietetic interpretation that the drink contains calories. However, the energy contents of energy drinks are very similar to levels found in other sweet beverages (Table 1). The quandary is that the drinks correctly state that they contain energy (kcals); however they are strongly communicating other meanings of the word. And this is the meaning that (young, male) consumers are receiving loud-and-clear. So what do food labelling experts mean by the word ‘energy’. Statements about energy are permitted on food labelling, but relate entirely to absolute

Table 1: Sugars and caffeine contents Per 100ml

kcals

sugars

caffeine

Red Bull

11g

32mg

Monster

11g

32mg

Rockstar

13.5

32mg

Lucozade energy*

8.7g

12mg

Coca cola

10.6g

10mg

Orange Juice

8.6g

50mg

Pro Plus tablet (1)

* Lucozade Energy contains less sugars but more energy than other similar drinks. This is because some of the carbohydrate in the ingredient ‘glucose syrup’ is in the form of oligosaccharide.

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NHD EXTRA: PUBLIC HEALTH

and relative amounts in relation to kcals content. They are defined by Regulation (EC) No 1924/2006, amended by Regulation (EU) No 1047/2012. Low energy means less than 40kcals per 100g (or half this for liquids). Energy-reduced means a value lower by at least 30% (compared to a standard or reference food). Lastly, energyfree means less than 4.0kcals per 100ml. And that is all. But there is an interesting development on the labelling of nutrients in foods versus nutrients in the body. An article 13.5 claim just approved by the European Commission in June 2016, allows statements on ‘lower blood sugar rise’ for products where at least 30% of sugars are replaced by non-digestible carbohydrates. The merge of labelling statements of (sugar) contents in foods to (sugar) levels in blood, suggests possible future concepts between energy contents in foods and ‘energy’ in the body. The term energy on food and drink labels appears to be multi-meaning and the Australian shopper is also confused.com. In a detailed interview of more than 400 shoppers in Sydney, packets of breakfast cereals, muesli bars and frozen meals were used to tease out the understanding of terms energy and calories. Results reported by Wendy Watson and colleagues were bizarre, but also very logical and understandable from the consumer viewpoint. Higher energy breakfast cereals were judged as healthier, as were, in contrast, lower energy ready meals. Participants with lower 58

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incomes were significantly more likely to state that higher energy products were healthier, the main reason being that these products were best for sustaining energy. Shockingly, only 40% of participants correctly recognised that kilojoules and kilocalories were different units for the same thing. The researchers were anxious that food energy concepts and units of measurement were a mystery to Australia shoppers and were concerned that further food and menu labelling initiatives expanding energy content declarations may result in accidental promotion of less healthy foods. A nutrition education campaign was needed (they concluded.) What else can be said about energy drinks? Caffeine is a well-described stimulant, and the content in energy drinks is about three times the levels in cola drinks per 100ml, although portion sizes in bullet cans may be smaller that cola cans or bottles (Table 1). All drinks containing more than 15mg caffeine per 100ml require labelling statements that the product is not suitable for children, or pregnant or breastfeeding women, and such statements are displayed. But there have been many concerns over the high caffeine content in energy drinks. And particularly their consumption by children. There is particular alarm that the promotion of (valid) claims about the effects of the stimulant caffeine, may lead people to believe in the (not valid) super-powers of energy drinks. In July 2016, the European Commission in Strasbourg was asked to adopt four health claims labelling statements on caffeine, approved by the

Table 2: EFSA approved health claims for caffeine Contributes to an increase in endurance performance Contributes to an increase in endurance capacity Helps increase alertness Helps to improve concentration

European Food Safety Agency (EFSA) (Table 2). These claims had been ‘on hold’ for more than five years. Although scientific data supporting stimulant effects is strongly based in evidence, approving such communication on food labels promises another marketing boost for energy drinks. The Danish MEP, Christel Schaldemose, strongly opposed the official yes-to-caffeine claims on labelling: survey data shows that nearly 80% of under-18 teens and nearly 20% of under10s, consumed energy drinks and further (mis) communication suggesting better performance in school or sport was irresponsible. In the vote, the concerns were accepted and approval of caffeine claims on labelling were rejected by the MEPs. The energy drinks industry was angry that caffeine in coffee was acceptable, but caffeine in non-coffee drinks was opposed. They called the outcome of the vote a disgraceful victory of politics over science, and taunted that energy-boosting claims could be made on such drinks regardless, by the additions of small amounts of B vitamins. Another marketing ingredient in energy drinks is taurine (except ‘marketing ingredient’ is unfair on caffeine, as it does have proven physiological effects). Between 2009-2011, various health claims regarding taurine were submitted for consideration to EFSA. Proposed statements included descriptions supporting physical and mental performance, and enhancing vitality. However, the substantiating evidence for all eight proposed claims was judged to be inadequate, and all labelling statements for taurine were not authorised. Some further specific assessments were made by EFSA in relation to the safety of the ingredient taurine. There had been anecdotal and case

reports of acute and adverse effects from drinking energy drinks, and an opinion was requested from the Panel on Food Additives and Nutrient Sources Added to Food. They calculated that the mean daily intakes of taurine from omnivore diets was at most 400mg per day, whereas the levels in a 250ml can was 4,000mg, so levels 10fold that of dietary intakes. Review of possible adverse cases suggested that very high amounts of energy drinks had been consumed (six cans per occasion) always combined with other factors such as intense exercise or alcohol. The Panel concluded that the possible adverse effects reported were more likely due to well described side effects of very high caffeine intakes; the possible relationship with high intakes of taurine lacked any scientific evidence. So, what is so get-up-and-go about energy drinks? They contain carbohydrates (sugars) and caffeine, but you could easily get this in a more enjoyable form, for example, with the classic combo of coffee and cake/cookie. They contain taurine and other marketing ingredients, which are not harmful, but which have not been demonstrated as effective either. Unlike other food and drinks, however, energy drinks do contain magic sparkle and ‘wings’ developed by many millions of pounds of sponsorship and advertising, communicating risk taking and physical vigour. The association between these images and these products explains why so many people are willing to pay £££s for small cans of fizzy drinks. It is time for more energy to be put into the critiquing of energy drinks and dietitians should be lassoing in the misleading and over-hyped claims of… bull.

Information sources: • Arens U (2009). A load of old bull. Network Health Dietitians Magazine; 59, 16 • EFSA (2009) Panel on Food Additives and Nutrient Sources Added to Food. The use of taurine and D-glucurono-gamma-lactone as constituents of the so-called ‘energy’ drinks. DOI: 10.2903/j.efsa.2009.935 • Harrison-Dunn AR. MEPs brew final caffeine claims battle as approval beckons. www.beveragedaily.com - 14 June 2016 • Harrison-Dunn AR. MEP caffeine vote ‘disgraceful’ victory of politics over science: Industry. www.foodnavigator.com - 8 July 2016 • Watson WL et al (2013). How well do Australian shoppers understand energy terms on food labels? Public Health Nutrition, 16, 03, 409-417

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NHD EXTRA: FOOD & DRINK

FUTURE FOODS FROM EDIBLE INSECTS Michèle Sadler Rank Nutrition Ltd

Michèle is Director of Rank Nutrition Ltd, which provides nutrition consultancy services to the food industry. Michèle has a BSc in Nutrition (University of London), a PhD in Biochemistry and Nutritional Toxicology (University of Surrey), and is a Registered Nutritionist.

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

Locally available edible insects are regularly eaten by around two billion people (over a quarter of the global population) across continents such as Africa, Asia and Latin America. Over 1,900 insect species are eaten, helping to improve the quality of traditional diets.1 With future food production needing to double in order to sustain the growing population (estimated to reach nine billion people by 2050) and to reduce chronic hunger, edible insects are seen as part of the solution. Production systems and the science of insects are currently at a pioneering stage. By merging modern scientific methods with traditional knowledge, both developing and developed countries can benefit from insects as a food source. This begs the question, can insects overcome their taboo in Western cultures, to become mainstream foods? WHICH INSECTS AND WHICH PRODUCTS?

Edible insects include familiar ones such as grasshoppers, ants and crickets, through to locusts, mealworms and termites. Table 1 shows the contribution to global consumption of the main orders of insects. After harvesting, insects can be freeze-dried, sundried, or boiled. They can be eaten whole, e.g. stir-fried or roasted, or they may be processed into powders, granular or paste forms that can be incorporated into combination foods such as breads, tortillas and snack bars. There is also potential to extract protein, fats and chitin from insects for use as food ingredients that can be added to enrich foods. Insects are already eaten as food in the USA and the UK. The current offer is mainly niche products and novelty snacks. Examples are cricket and mealworm powders, whole

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roasted crickets and mealworms, frozen blanched locusts for use in stir-fries and Bodhi protein bars made with cricket powder. Top end restaurants are also experimenting with whole insects and insect powders. And of course, cochineal (carminic acid) is a long-standing food colouring that is extracted from scale insects (Dactylopious coccus). WHY EAT INSECTS?

Human entomophagy (eating of insects) tends to be traditional where conventional sources of protein such as meat and fish are unavailable or in low supply. While insects can make a significant nutritional contribution to many human populations they are also viewed as a delicacy. Two main advantages of potential relevance to developed countries are their high nutritional value and their contribution to sustainable diets. Nutritional value The Food and Agriculture Organisation of the United Nations (FAO), working with INFOODS (the International Network of Food Data Systems), established in 1984, has collected available nutritional data for edible insects as part of its programme to promote biodiversity. This includes collecting data on wild and underused foods at various levels including variety, cultivar and breed.1 Insects have a number of favourable nutritional attributes. The wide variation in nutritional content not only reflects the large variety of different species, but also differences within

Table 1: Commonly consumed insects

Insect Order

Proportion of global insect consumption

Insects

Coleoptera

31%

Beetles (inc mealworms)

Lepidoptera

18%

Caterpillars

Hymenoptera

14%

Bees, wasps, ants

Orthoptera

13%

Grasshoppers, locusts, crickets

Hemiptera

10%

Cicadas, leafhoppers, planthoppers, scale insects and true bugs

Isoptera

Termites

Odonata

Dragonflies

Diptera

Flies

Other orders

Other insects

Data from: FAO, 2013. Edible insects - Future prospects for food and reed security. FAO Forestry paper 171. Rome: FAO, 2013.

individual species which may be due to the metamorphic stage of the insects at harvesting (e.g. adult stage, larvae, pupae or eggs), to their habitat (e.g. wild or farmed), differences in their diet and how they are processed. Uniform feeding and controlled production leads to more reliable quality and consistency, which is important for food labelling and quality control. In general, edible insects provide useful amounts of energy, protein of high value, unsaturated fats and an array of micronutrients. Reported energy values for a number of insect species range from 293 to 762kcal/100g dry weight.2 On a fresh weight basis, the protein content of adult locusts, termites and grasshoppers compares favourably with beef and fish.1 As to protein quality, edible insects can provide a useful addition to traditional diets by increasing intake of the limiting amino acid. For example, many insect species are a good source of lysine and can thus supplement diets where the key staples are cereal proteins which are often low in lysine. In the UK, the limiting amino acid in the overall diet is threonine and many insect foods are a good source of this amino acid. Edible insects are also a useful source of unsaturated fat and frequently provide the essential fatty acids linoleic and a-linolenic acid, the fatty acid composition being influenced by the insectsâ&#x20AC;&#x2122; diet. The micronutrient content varies considerably by species and

more research is needed, particularly into bioavailability. However, many edible insects are rich in iron and zinc, some providing more than red meats. Some species provide high levels of vitamin E and many insects are a good source of B vitamins, including some that provide useful amounts of vitamin B12. Of particular interest is the generally high fibre content of insects. This is mainly in the form of chitin, a long-chain polymer of N-acetyl glucosamine which is a derivative of glucose. Chitin forms the main component of the exoskeleton of insects. Table 2 overleaf shows the nutritional content of two example insect powders currently on the market in the UK, sourced from a controlled production system in Canada. Sustainability With increasing emphasis on sustainable diets, i.e. diets that contribute to food and nutrition security, while having a low environmental impact and respecting biodiversity and ecosystems,3 edible insects are generally considered to be prime candidates as both food staples and dietary supplements.1 Rearing insects is thought to result in lower ammonia and lower greenhouse gas emissions than arise from farming pigs or cattle, with less land and water required. There is also the possibility to rear insets on organic side-streams and the potential to reduce environmental contamination.1 www.NHDmag.com August / September 2016 - Issue 117

NHD EXTRA: FOOD & DRINK

. . . the use of insects as food certainly has potential as an emerging food source, depending of course on consumer acceptance. It goes without saying that introducing a new food comes with a range of challenges. The Food Standards Agency (FSA) has recently called for information about insects for human consumption and attention is being focused on knowledge development for the possibilities of consuming insects in the UK. CURRENT REGULATORY STATUS IN EUROPE

Whole insects and whole insect powders do not currently fall within novel foods provisions. However, they will fall under the scope of the new novel food regulations that were adopted in 2015,4 that come into force in January 2018. As insects are already on the EU market, there is a two-year period to submit a dossier requesting authorisation. Extracts such as proteins and oils are not currently allowed to be sold in the EU and will also require novel foods approval. A further main use for insects is as a feed source for animals and fish and the regulatory status of insects for this purpose is currently being reviewed. EFSA published an opinion on the risk profile of insects as food and animal feed.5 It was noted that there is no systematically collected data on human consumption of insects. EFSA reviewed a wide range of potential safety issues and recommended that research is undertaken to address the gaps in the data. However, the FSA has indicated that it is not aware of any public health concerns. 62

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NEW FOODS AND CONSUMER ACCEPTANCE

There are various examples of new foods introduced to the UK market in recent decades. Foods may be classed as â&#x20AC;&#x2DC;newâ&#x20AC;&#x2122; for different reasons. An obvious example is food produced by a new technology, e.g. genetic modification (GM). Tomato puree produced from GM tomatoes introduced in the 1990s was initially well accepted, being slightly cheaper than conventional tomato puree. However, the introduction of the more ubiquitous GM soya with no consumer benefits resulted in rejection of GM foods and a prolonged absence of GM technology from the market.6 A number of novel foods and ingredients, i.e. not previously on the EU market before May 1997, have also been granted approval, such as chia seeds, noni juice, plant sterols, new sweeteners and new sources of micronutrients. The genuinely new food Quorn was successfully introduced in the 1980s, gaining consumer acceptance as a meat alternative. It has since become well established in many different global markets, offering the clear consumer benefits of excellent eating quality, combined with a low fat content and containing useful amounts of fibre.7,8 Exotic meats have also been introduced to the UK in the past decade or so, such as kangaroo, crocodile and bison, though these remain as niche products.

Table 2: Nutritional value of insect powders available in the UK

Nutrient

Cricket Powder

Mealworm Powder

472

436

Fat (g)

18.9

Saturates (g)

8.5

4.1

Monounsaturates (g)

5.1

6.5

Polyunsaturates (g)

9.1

7.3

Omega – 3 fatty acids (g)

2.8

N/A

Omega – 6 fatty acids (g)

6.3

N/A

Carbohydrates (g)

8.4

15.4

Sugars (g)

0.5

8.7

Energy (kcal)

Fibre (g) Protein (g)

Salt (g)

0.9

0.5

110/0

81.0

Iron (mg)

2.5

3.7

Potassium (g)

1.1

Vitamin B12 (ìg)

31.0

N/A

Calcium (mg)

Data from Mophagy (www.mophagy.com).

So, the use of insects as food certainly has potential as an emerging food source, depending of course on consumer acceptance. Alongside crustaceans, insects are also classed as arthropods. This raises the question that if as a society we are okay with eating shellfish, such as winkles, lobsters, crabs and crayfish, and with eating snails, then why not insects? We tend to view insects as pests and carriers of diseases and the thought of eating insects is initially repulsive to many people. So can this be overcome? Consumer research suggests that processing insects so that they are unrecognisable may make them more acceptable, and that males are more likely than females to consider trying them, as are people interested in food sustainability, those already familiar with insects from other food cultures and those who want to reduce their intake of red meat.9 CAN INSECT FOODS PLAY A ROLE IN THE UK DIET?

As well as the challenge of consumer acceptance, insect foods are relatively expensive in

comparison with traditional meats. Scaling up production to reduce costs will involve many different disciplines and such challenges are currently being addressed. Can we overcome these barriers to accept insects as foods and if so, what roles could they play in the UK diet where we already have a varied food supply and a large choice of nutritious foods? Insects undoubtedly have novelty value and will be of interest to ‘foodies’ and the more adventurous among the population. But can they become more than niche products? Edible insects are certainly valuable nutritionally and could supply additional protein, fats and micronutrients to population groups with specific needs such as the elderly and patient groups on special diets or recovering from illness. They could also be useful for sports foods. Use of insect powders to enrich traditional foods that we are used to eating may be a way to introduce them to the diet in a more acceptable way for consumers. So, how adventurous is the UK population well, let’s wait and see! www.NHDmag.com August / September 2016 - Issue 117

NHD EXTRA: NUTRITION MANAGEMENT

CASE STUDY: SPORTS NUTRITION Helen Phadnis Freelance Dietitian and Sports Nutritionist Helen’s practice is underpinned by over 10 years of previous clinical experience at a senior specialist level and five years in private practice. She provides workshops for local clubs and teams and runs clinics in Brighton and Hove. helen@nomnomn e rd.com http://www.nomn o mnerd.com/

The effects on body composition of a K2 summit attempt by an experienced climber Climbing at altitude puts additional energy demands on climbers, estimated at an extra 536kcal/d just for acclimatising to altitude,1 and 1,610kcal/d for climbing activities.2 Alongside these demands come welldocumented changes in taste perception and reduced appetite,3 making weight loss inevitable when climbing above 5,000m. K2 is the second highest mountain in the world, at 8,611 metres above sea level. It is known as the ‘Savage Mountain’ due to the extreme difficulty of ascent.

Matt is a 38-year-old experienced mountain climber planning a second attempt at reaching the summit of K2. Matt was seeking nutritional advice in an attempt to minimise weight loss experienced during his previous attempted summit of K2 two years prior. His trip had resulted in 17% weight loss from 100kg to 83kg. After initial basic dietary advice was provided, Matt requested an in-depth body composition assessment pre- and post- K2 expedition out of curiosity, to see the anthropometrical effects on his own body of climbing at altitude.

Identification of Nutritional Need 1. Assessment Medical diagnosis: Susceptibility to cold sores Anthropometric measurements: Body fat and lean mass measurements were taken via multiple frequency bioelectrical impedance, using Body Composition Monitor (BCM), Fresenius Medical Care (see Table 1). Skinfold thickness measurements were taken at seven sites using Harpenden Skinfold Calipers. Girth measurements were taken with a tape measure. Takei 5001 hand grip dynamometer was used to assess muscle strength. Seven-point Subjective Global Assessment scale was used to assess nutritional status. Dietary Intake Analysis Planned daily intake during climbing is documented in Figure 1. This was based on previous experience of what is possible to carry with regards to weight during a climb, as well as what is palatable. This would provide approximately 2,500kcal, 64g protein. From previous experience, in keeping with what is commonly reported in climbers at altitude, Matt knew he could tolerate carbohydrates in preference to fat when eating during a climb. Recommended Body Weight: BMI 18-25kg/m2 = 64-88kg Recommended body composition based on published elite sport climbers and high altitude climber anthropometry data4,5 is recorded in Table 1. Estimated energy needs: Using actual body weight (as client is not obese) BMR (Schofield) 11.5 (101.7) +873 = 2042 x 1.9 PAL = 3880kcal/d Nitrogen (Elia) 0.17 x 101.7 = x6.25 = 108g/d Based on ACSM Nutrition in Sport Position stand6 Very high carbohydrate needs (mod-high intensity exercise over >4-5 hours). Target 8-12g/kg/d = 813-1229g carbohydrate = 3,089-4,670kcal Protein = 1.2-2g/kg/d = 122-203g protein = 488-812kcal Total discounting fat = 3,577-5,482kcal/d Medications: None Supplements: Centrum multivitamin and mineral supplement.

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2. Identification of nutrition and dietetic diagnosis Diagnosis: Inevitable cachexia expected during planned K2 climb. Aims: To minimise negative effects of altitude on dietary intake and resultant muscle loss and fatigue during K2 climb. To assess body composition and compare to that documented for high altitude climbers. 3. Plan nutrition and dietetic intervention Nutrition Prescription: I. Prevent injury and illness during trip. a. Take probiotics e.g. Actimel daily for two weeks prior to trip to reduce likelihood of contracting diarrhoea. b. Probiotic tablet daily during trip. c. To take a broad spectrum multivitamin and mineral supplement daily during trip and pre-trip to reduce susceptibility to cold sores and upper respiratory tract infections. This will cover all micronutrient requirements when the effects of altitude cause a reduction total diet intake. d. Aim for adequate calories and protein during trip: supplement planned nutritional intake with Complan meal replacements and some medium Glycaemic Index snacks such as chocolate, fruit and nut bars. II. Optimise performance during climb. a. Match food intake to energy expenditure as far as is possible: i. Pack familiar palatable food to tempt into eating as much as possible: small frequent snacks to optimise intake. ii. Include high fat foods if possible: cheese, chocolate, fish in oil. III. Prevent loss of lean body mass during climb. a. As above. IV. Prevent dehydration a. Rehydration is more effective when there are some electrolytes and/or calories present: always drink when take food, preferably salty snacks. Aim for 4-5L when at altitude if possible. 4. Implement nutrition and dietetic intervention I talked Matt through the above nutrition prescription, alongside advice on basic principles of sports nutrition and how they could be applied on the trip as well as to his pre-expedition training. A key element when considering 10-15 hour climbs with no stop for a proper meal was aiming for 30-60g carbohydrate per hour to minimise fatigue. 5. Monitor and review See Table 1: Anthropometry I. Matt’s body mass index was above the healthy range before the trip. Abdominal circumference and sum of skinfolds were also high, indicating excess fat before the trip. After the trip, total fat stores fell by 8.0kg, the most significant loss being from abdominal stores, indicating healthy weight loss. II. Results from the body composition monitor show that a far larger proportion of weight lost was fat (about 8.0kg), compared to muscle (about 2.0kg). This is attributable both to Matt’s persistence with taking on board nutrition during the trip, and also due to the fact that he was exercising daily during the expedition. III. Subjective global assessment classed Matt as ‘at risk’ of malnutrition post-expedition. Also the rate at which he lost weight during the expedition was 12.5% loss body weight in three months. This is clinically significant for malnutrition. However on his return: a. Matt was unlikely to be deficient in vitamins and minerals due to daily supplementation during the trip and did not display any symptoms of micronutrient deficiency; b. daily exercise led to fat loss in preference to muscle loss. Body mass index within the healthy range for athletes; c. despite a lack of appetite, Matt was not suffering from any other adverse gastro-intestinal symptoms. IV. Muscle bulk was reduced post-trip and as a result Matt lost some power, as indicated by reduced handgrip strength. Matt was counselled on recovery snacks containing 20g protein along with carbohydrate to encourage regain of muscle stores. He was also encouraged to self-monitor his nutritional status via waist circumference measurements, aiming to minimise fat regain in this area. It was recommended that his multivitamin and mineral supplement was only necessary at times of intense training or life stress. 6. Evaluation Loss of both fat and muscle are inevitable whilst climbing at high altitude. This can be minimised by good planning and implementation of a calorie dense diet comprised of tried and tested meals, snacks and supplements. www.NHDmag.com August / September 2016 - Issue 117

NHD EXTRA: NUTRITION MANAGEMENT Table 1: Nutrition Assessment Data Reference range *Elite sport climbers5 # High altitude climbers4

Pre-trip

Post-trip

Height m

*1.72

1.884

Weight kg

*65.5 #69-85

101.7

88.5 on immediate return 92.5 at appointment

Body Mass Index (BMI)

WHO 18.5-25kg/m2

28.6 kg/m2

25kg/m2 on immediate return 26kg/m2 at appointment

% weight loss past 3 months

Stable = <5%

9% (12.5% total)

Hydration L

Euhydrated = 0

-0.4 L

+1.2L

Body fat %

*6.8-12.7

26.4 7.3% (from skinfolds)

21.9 5.7 (from sfs)

Fat mass kg

*8.6 #4.9-13.1

7.4kg (from sfs) 36.6

5.3kg 27.5

Lean mass kg

#20.7-42.2

66.1

64.2

Subjective Global Assessment

Well nourished = 6-7, at risk = 4-5, Malnourished = 1-3

Hand Grip Strength

76-176

138

117

Triceps Circ (+-flex) cm SF mm

# 28-34 6.5-19

35.7, flex 36.4 7.2

33, flex 34.5 6.2

3.8

5.5

Biceps skinfold mm Chest skinfold

# 5-13.5

3.8

3.2

Abdomen Circumference skinfold

# 82-96 7-21

94 13.0

87.5 11.0

Subscapular skinfold

# 8-16

13.8

9.0

Suprailiac skinfold

# 8-21.5

7.2

4.95

Thigh Circumference skinfold

# 55-61 7-14

65.1 4.8

56.4 5.2

Calf Circumference skinfold

# 37-39

46.2 11.5

44.5 8.0

57.5

44.35

Sum of 6 skinfolds

Abdomen circ: <94cm = healthy, 94-102cm = increasing health risks, >102cm = high health risks.

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Figure 1: MGâ&#x20AC;&#x2122;s original planned dietary intake when climbing

Planned daily intake during climbing . . . This was based on previous experience of what is possible to carry with regards to weight during a climb, as well as what is palatable. References 1 Pulfrey SM and Jones PJH (1996). Energy expenditure and requirement while climbing above 6,000m. J Appl Physiol 81: 1306-1311 2 Westerterp KR, Saris WHM, Van Es M and Ten Hoor R (1986). Use of the doubly labeled water technique during sustained heavy exercise. J Appl Physiol 61: 2162-2167 3 Anonymous (1938). Nutrition panel of the food group. J Soc Chem Ind 57: 1230-1234 4 Reynolds RD, Lickteig JA, Howard MP and Deuster PA (1998). Intakes of high fat and high carbohydrate foods by humans increased with exposure to increasing altitude during an expedition to Mt Everest. The Journal of Nutrition pp50-55 5 Romero et al (2009). Body fat measurements in elite sport climbers: Comparison of skinfold thickness equations with dual energy X-ray absorptiometry Journal of Sports Sciences 27(5): 469-477 6 American College of Sports Medicine, Dietitians of Canada, the Academy of Nutrition and Dietetics (Feb 2006). joint Position Stand on Nutrition and Athletic Performance

dieteticJOBS.co.uk To place an ad or discuss your requirements please call

0845 450 2125 (local rate)

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PAEDIATRIC NHD EXTRA: COMMUNITY

A DAY IN THE LIFE OF . . . A MEALS ON WHEELS NUTRITIONIST Annabelle de la Bertauche Registered Nutritionist Hertfordshire Independent Living Service (HILS)

Annabelle is currently working for Hertfordshire Independent Living Service (HILS), the largest meals-on-wheels provider in the country. She has held a variety of roles including nutrition research, Government policy and advice, healthy eating education for children and, most recently, with older people who are living with dementia and/or depression in the community at Age UK Hertfordshire.

ANNABELLE’S DIARY

9am - 12noon: I spend a busy morning delivering our Referrer Training to a team of charity workers. The team requested our specialist training as their work involves supporting older people in their homes, and they are always keen to improve their knowledge to better help their clients. We provide this training to any groups in Hertfordshire that want to support older and vulnerable people to eat well and help prevent dehydration and malnutrition. Taking just a few hours, our training covers how to identify the signs of malnutrition and what they can do to help. The team are so enthusiastic and curious about the subject matter that we have a fantastic morning of active discussion. 12:30 - 13:45: Lunch meeting I pop back to the office for a working lunch meeting to discuss our next project around eating well with dementia. We don’t have these meetings that often, but when we do, we choose one of our own (HILS) meals. Today I have chosen the vegetarian sausage casserole followed by ginger sponge and custard. It was delicious and I am now recharged and ready for the rest of the day. 14:00 - 15:00: I visit a client (accompanied by her daughter) to carry out a Nutrition and Wellbeing check. Our free Nutrition and Wellbeing check involves calculating Body Mass Index (BMI), by taking a weight and height measurement, assessing

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Nutrition training

for malnutrition risk using the Malnutrition Universal Screening Tool (MUST) and also exploring health and dietary needs through an informal questionnaire and discussion. The client has a healthy BMI and a good appetite and, importantly, she is enjoying our meals. However, we do identify that she isn’t drinking the recommended six to eight cups of fluid each day. The client knows how much she should be drinking and her daughter admits to have been ‘nagging her for months’ about it. After some enquiry about continence issues she reveals that she has been holding back from drinking due to having not made it to the toilet in time on a few occasions. I reassure her that this is a very common problem, but keeping herself in a state of dehydration will not help with this and will put her at increased risk of some very serious issues such as urinary infections and falls. They were both unaware of the dedicated NHS Continence Service that we have in Hertfordshire, and they agree for me to refer her directly. She also happily accepts one of our free water jugs and agrees that it would be useful if a drink could be prepared for her by the HILS Community team member who delivers her meal each day.

15:15 - 15:45: I carry out another client Wellbeing check; however, this time it’s a followup review for a client who I saw three months ago. At that time, he had an underweight BMI and had reported significant weight loss in the few months prior to my visit. He has since been receiving both our higher energy

meals and our ‘Nutrition Boost’ snacks, which we provided at no extra cost. Our ‘Nutrition Boosts’ are a few free extra items of food delivered with his meal each day. They are given to clients who are identified as being at risk of malnutrition. Nutrition Boost items include fortified soups, milky drinks and a variety of tasty snacks, all carefully selected so that they are small portions, but contain at least 200kcal each. Today, three months on, I find that he has put on 8lb which is great news.

16:00 - 17:30: I write up the summary letters to send to the clients I have seen and catch up on a few emails. An urgent email explains that we have a client who is allergic to Capsaicin (present in chilli peppers, bell peppers and paprika). I use our supplier’s dedicated nutrition software to run a search on these ingredients and send a list of our meals that do not contain them to our support teams, so that they can remove all of these meals from the client’s personalised menu profile. I also have several emails in my inbox from the support teams letting us know about new clients who would like a Wellbeing check, as well as messages from community groups who would like training. And so the work continues!

NETWORK HEALTH DIGEST