Network Health Digest - November 2016 - issue 119 by NH Publishing Ltd

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

NHDmag.com

November 2016: Issue 119

EATING DISORDERS weight - shape - size

FOLLOW-ON FORMULA INTRODUCING SOLID FOODS MEAL REPLACEMENTS GLUTEN-FREE PRODUCT LIST

COPD Pages 25 to 29

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FROM THE EDITOR

WELCOME Emma Coates Editor

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

So, how are you bearing up now we have turned the clocks back and we’ve moved into shorter days, with darker mornings and murky evenings? I hope your circadian rhythm hasn’t been too affected, meaning you now harbour a deep desire to hibernate like a bear. Whilst bears have some sense in hiding away for the long cold winter, they’d actually miss out on this generously filled digital issue of NHD. And that won’t do! NHD stands for ‘Network Health Digest’, not ‘Now Hibernate, Darling’! We’ve harvested a good supply of clinical dietetic and nutrition articles to fuel your appetite for current knowledge and evidence throughout this month. That feast of information might make you thirsty; but fear not, Ursula Arens is on hand to serve you some Hard facts on soft drinks, where she takes a closer look at this industry and what we are preferring to guzzle down. Sugar intake is, as always, a hot topic and new research from Dr Jana Anderson and Prof Jill Pell (page 10) is enlightening. The management of eating disorder (ED) patients is challenging but rewarding work; but, for non-specialist ED dietitians working without the support of a specialist ED MDT, these patients can prove all the more challenging. Our Cover Story by Nikki Brierley RD aims to support non-specialist dietitians who may well encounter patients with a diagnosed or suspected ED. Nikki shares her knowledge and advice on the community-based management of ED. Anne Myers Wright RD takes us through the management of COPD in the obese patient; looking closely at the impact it has on outcomes and approaches to weight management in this patient group. Continuing with the theme of obesity, Maria Dow RD discusses the role of Meal replacements in obesity management. Maria investigates the various options available and the evidence to support their use.

Naomi Johnson, BSNA, gives us an overview of current evidence and recommendations for enhanced recovery after surgery (ERAS) and the role nutrition plays here. We also welcome back Ali Hutton RD with a comprehensive overview of Coeliac disease and bone health in adults. We also include our useful Gluten-free product list on page 39. Our paediatric articles this month cover follow-on formulas, with an overview article and case study from Jacqui Lowdon RD, where she discusses the current recommendations for this group of products; and the introduction of solid foods for babies, where Alison O’Sullivan RD shares her insights in to supporting parents during this challenging and exciting time. We also have our range of excellent regular features including our Food for thought news round-up from Dr Emma Derbyshire RD and as always The Final Helping from Neil Donnelly. There are also the online resources, Student zone and eCPD features here . . . Plus NHD Extra with dietary fatty acids being the topic of discussion for Maeve Hanan RD, where she delves into the research behind some of those headlines, such as ‘butter is back’ and summarises the current public health messages for this nutrient group. If a well-known sugary, caffeinated soft drink gives you wings, NHD gives you more information than you can shake a stick at (not quite as catchy but probably more use than wings and infinitely healthier than the well-known sugary, caffeinated soft drink!). Cheers! Emma www.NHDmag.com November 2016 - Issue 119

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CONTENTS

14 COVER STORY Eating Disorders weight - shape - size

News

43 INTRODUCING SOLID FOODS

Latest industry and product updates

10 New research Recent study into sugar and obesity 12 Soft drinks Hard facts on hydration 19 Follow-on formula Complementary feeding

25 COPD

Support for parents 48 Meal replacements Obesity management 51 Book review Food and Nutrition Economics

The impact of obesity

Copies to give away

53 Web watch Online resources

and updates

31 Enhanced recovery after surgery The role of nutrition

55 Events & courses Dates for your diary

35 Coeliac disease Managing bone health in adults 39 Gluten-free product list A comprehensive resource

56 The final helping The last word from Neil Donnelly

Copyright 2016. All rights reserved. NH Publishing Ltd. 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

ISSN 2398-8754

www.NHDmag.com November 2016 - Issue 119

NEWS

FOOD FOR THOUGHT

Dr Emma Derbyshire PhD RNutr Dr Emma Derbyshire heads Nutritional Insight Ltd, an independent consultancy to industry, government and PR agencies. She is an avid writer for academic journals and media. Her specialist areas are maternal nutrition, child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire

UK NDNS data reveals ongoing problems The latest set of data from years five and six (2012 to 2014) of the UK National Diet & Nutrition Survey (NDNS) has been published, highlighting some dietary shifts and ongoing problems (Table 1). In terms of dietary shifts, daily intakes of sugar-sweetened soft drinks have reduced in children aged 4-10 years; from 130g per day in 2008-2010 to 100g per day (though thereâ&#x20AC;&#x2122;s still work to be done). There has also been a downward trend in adult red and processed meat intakes compared with previous years. With regard to ongoing problems, fruit and veg intakes remain low: children aged 11 to 18 years are eating just 2.8 portions daily; equivalent to 8% meeting the 5-A-Day recommendation. As in previous surveys, mean intakes of oily fish were below the recommended one portion per week across the board. Non-starch polysaccharides (NSP) were also inadequate in adults and below recommendations of 18g per day. In terms of micronutrients, just under half (48%) of women aged 11 to 18 years and a third (27%) of women aged 19 to 64 years had low iron intakes. There was also evidence of low vitamin B12 status amongst girls and adults. For vitamin D, one-fifth of adults had low blood levels of vitamin D. A substantial proportion of adults also had intakes of magnesium, potassium and selenium below the Lower Reference Nutrient Intake. Overall, these findings indicate that whilst there have been some movements, there is still much work to be done! This includes improving fruit and veg, fibre and oily fish intakes along with iron and vitamin D shortfalls. There is also a clear need to now refer to AOAC rather than NSP fibre in future reports (expected to be after year seven), to align with updated guidelines. For further information, see: Bates B et al (2016). National Diet and Nutrition Survey Results from Years 5 and 6 (combined) of the Rolling Programme (2012/2013 - 2013/2014). FSA and PHE: London.

Table 1: Main NDNS findings (2016) 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.

Food group

Main findings

Fruit and vegetables

Mean consumption for children aged 11-18 years was only 2.8 portions/day; Only 27% adults aged 19-64 years and 35% >65 years met the 5-A-Day recommendation

Red and processed meat

Adult males exceeded the recommended 70g per day

Oily fish

Intakes were below the recommended one portion per week in all population groups

Saturated fatty acids

Exceeded current recommendation (no more than 11% of food energy) across all age groups

Non-starch polysaccharides (NSP)

Mean intakes remain well below the dietary reference value

Sugar-sweetened soft drinks

Significant reductions in children aged 4-10 years

Non-milk extrinsic sugars (NMES)

Exceeded the recommendation (no more than 11% of food energy) for all age/sex groups except women aged 65 years and over

Vitamin A

16% of children aged 11 to 18 years had intakes below the LRNI for vitamin A

Vitamin B2

Both girls and women had intakes below the LRNI

Vitamin B12

Blood samples revealed low B12 status in all age groups

Vitamin D

One in five adults had low blood levels of vitamin D

Iron

48% of girls aged 11 to 18 years and 27% women had iron intakes below the LRNI

Key: LRNI, Lower Reference Nutrient Intake

www.NHDmag.com November 2016 - Issue 119

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NEWS FIBRE IN INFANCY HELPS TO SUPPORT LATER HEART HEALTH A wealth of evidence has examined how dietary fibre affects factors such as hypertension, obesity, insulin sensitivity and elevated cholesterol in adults. However, until now the effects of fibre intakes in infancy appear to have been overlooked. New research from the University Medical Centre and Leiden University in the Netherlands used data from the Generation R Study to assess dietary fibre intakes of 2,032 children at age 12.9 months and six years. Five key markers of cardiometabolic health were measured. Results revealed that just 1.0g per day of energy-adjusted dietary fibre was associated with higher HDL cholesterol and lower triglycerides, but was not linked to body fat percentage, insulin or blood pressure. These findings suggest that the benefits of dietary fibre on cardiometabolic health may track right back to infancy. Further research is now needed to replicate these findings.

DOES DRINKING WATER BOOST BRAIN FUNCTION? Water is one of the healthiest ways to hydrate. Whilst some research has looked at hydration and cognition (brain function), this has mainly been in children. New work, has now studied how hypohydration (low hydration levels) could affect the cognition of 18- to 30-year olds. A total of 101 young people were randomly o allocated to drink 300ml water or not in 30 C conditions for four hours. During this time, changes in body mass, urine osmolality, body temperature, thirst, episodic memory, focused attention and mood were measured. Findings showed that drinking water improved memory and focused attention. Over the four hours, thirst was first associated with reduced memory. As time went on, body mass losses were linked to reduced memory and attention. By 90 minutes, heightened thirst sensations were linked to increased anxiety and depression. By 180 minutes, those drinking the water found the memory tests easier. These are interesting findings showing how water restriction can affect how our minds work over time. This is also the first study to show that drinking water can help to support cognitive function when there is a 1% body mass loss (which can occur during everyday living).

8, Issue 9 pg 531.

Journal of Clinical Nutrition. Vol 104, No 3, pg 603-12.

For further information, see: van Gijssel et al (2016). Nutrients Vol

For further information, see: Benton D et al (2016). American

CARRYING TWINS OR MULTIPLES DRIVES UP IRON DEFICIENCY RISK Anaemia in pregnancy, typically in later trimesters, is a common problem which can affect the health of the mother and child. Whilst much is known about singleton pregnancies, the iron demands of women having multiples has not being studied in much detail. New research has now looked at this. An article published in The American Journal of Clinical Nutrition analysed blood samples of 83 women, aged 20-46 years, carrying twins, triplets or quadruplets. This was carried out at week 24 and delivery. Iron deficiency increased significantly from pregnancy to delivery. Overall results revealed that 44.6% of women were anaemic at delivery and 18% developed iron deficiency anaemia. Of most concern was the fact that those with depleted iron stores during pregnancy had a two-fold greater risk of anaemia, suggesting that supplementation may be justified for multiple gestations. These are interesting findings and worthy of further exploration. Given that the recent National Diet & Nutrition Survey reveals that high proportions of UK women have low iron intakes and status, this signifies that the problem should be addressed even prior to conception. For further information, see: Ru Y et al (2016). American Journal of Clinical Nutrition [Epub ahead of print].

www.NHDmag.com November 2016 - Issue 119

BDA AWARDS Every year the British Dietetic Association (BDA) recognises the achievements of dietitians through their Awards. The BDA General Education Trust offers three annual awards: Rose Simmonds, Dame Barbara Clayton and Elizabeth Washington. The winner of the Elizabeth Washington Award will receive £1,500, and will be invited to present their work at a National BDA Event. This is a great opportunity for all BDA dietitian members to present published, or recently available, educational work. For this award the work can be an article, journal paper, department resource, e-learning material, text book chapter, booklet or website content. The submitted work does not have to be research published in a journal. It must be educational, addressing an audience of dietitians, professional colleagues, students, patients or the general public. The criteria is very broad. The award is open to all dietitian members. This is a chance to achieve national recognition from your professional body for your every-day practice. It also provides an excellent CPD opportunity in terms of the award and presenting the piece at the BDA national event and other relevant events. Please consider discussing this opportunity at departmental meetings and amongst your colleagues and friends. The Rose Simmonds Award is for an original research publication in the last two years. This should be a scientific piece of work and must be published in print in a peer reviewed journal. Members who are first time published are particularly encouraged to apply. Open to all full members, the winner will receive £2,000. The Dame Barbara Clayton Award encourages applications from projects which have encouraged new ways of working in an innovative way. It must be BDA member led and the focus should be a dietetic intervention, which demonstrates positive outcomes for the profession and the service user. The winner of this award receives £1,500. The application must be submitted by at least one BDA member involved in the work. The deadline for submission for all three awards is 6th January 2017.

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www.NHDmag.com November 2016 - Issue 119

NEW RESEARCH

SUGAR IS THE NUMBER ONE TARGET IN THE WAR ON OBESITY: BUT IS IT REALLY TO BLAME? Dr Jana Anderson

Prof Jill Pell

Dr Jana Anderson is a research associate working in the Public Health research in the Institute of Health and Wellbeing at the University of Glasgow. Jana’s main research interests are lifestyle factors, such as diet and physical activity and their impact on health. Prof Jill Pell is the Henry Mechan Professor of Public Health and Director of the Institute of Health and Wellbeing at the University of Glasgow. She is also an Honorary Consultant in Public Health in Greater Glasgow and Clyde Health Board.

In a recent study, published in The International Journal of Epidemiology, Dr Anderson and Professor Pell et al examined the extent to which sugar, relative to other macronutrients, was associated with adiposity. Here they examine the background to the study and share with us their key findings. Earlier this year, the Chancellor of the Exchequer announced that a tax on sugary drinks will be implemented from April 2018. Drinks containing 5.0-8.0g of sugar will be taxed at 18pence/litre and those containing more than 8.0g at 24pence/litre.1 It has been estimated that the sugar tax will generate an additional £520m in revenue in its first year.3 In England, the money raised by the new tax will be used to increase funding for sports in primary schools. Why have sugary drinks been singled out? Compared with other sweet foods, people are less aware of the high calorie content and they do not consider them as treats. Because they do not contribute to satiety, they are consumed in addition to other foods, not instead of them. Also, children and young adults are the most common consumers of sugary drinks; therefore, the sugar tax may specifically combat the worrying childhood obesity epidemic.2 Whether the tax succeeds in its aim of reducing sugar consumption will depend on many other factors, such as whether the tax has been set sufficiently high to impact on affordability as well as cost, the extent to which consumers will accommodate increased cost by making other changes in their spending (price elasticity), and the extent to which drinks producers proactively protect their market by reducing the sugar content of their products. If the sugar tax does reduce consumption of sugar, will it solve the obesity epidemic? The current focus on

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sugary drinks and snacks might suggest that it is sugar specifically, rather than calories more generally, that causes obesity. We tested this in our study published recently in The International Journal of Epidemiology,4 in which we analysed data collected on more than 132,479 members of the general public who took part in UK Biobank. Compared with slim people, the diets of obese people contained 12% more calories and 15% more fat, but only 5% more sugar. Therefore, the main predictors of obesity were overall calories and fat consumption, rather than sugar consumption. These findings suggest that if the only effect of the sugar tax is to reduce sugar consumption this will have some impact on obesity, but is unlikely to provide the full solution. But will this be the only impact of the sugar tax? It might be tempting to assume that a tax that discourages sugar consumption might also result in a general improvement in diet. However, there is evidence of a ‘sugar-fat see-saw’ whereby, if people focus specifically on reducing consumption of one, they compensate by eating more of the other. Furthermore, our study showed a relatively low correlation between sugar and fat intake; the people who consume the most sugar are not necessarily the ones who consume most fat, and vice versa. This leads to the possibility that measures which over-emphasise sugar consumption may lead to a paradoxical increase in fat, thereby obviating any beneficial impact on obesity. So where does this leave us? Sugar

provides empty calories. It is nonessential for anyone other than, possibly, endurance athletes. It is a specific risk factor for dental caries, but its contribution to obesity is not specific but rather as a result of its contribution to our excessive consumption of overall calories. Therefore, whilst it is desirable to reduce our sugar consumption by relegating it to an occasional treat, we need to ensure that any public health interventions or messages clearly emphasise that reduction in sugar consumption must be done within the context of reducing overall calories. So instead of aiming a single bullet at sugar, we need a smart bomb to combat all of the culprits. THE RESULTS

We found evidence that people who are overweight or obese do consume, on a daily basis, more sugar (by 4.7%). However, they also consumed significantly more fat (14.6%), protein (by 13.8%) and starch (by 9.5%). This results in a significantly higher total daily calories intake (by 11.5%). We also looked at how much individual macronutrients contribute to the overall intake of calories. We

found that overweight and obese people get proportionally less calories from sugar than people with normal weight (22.0% vs 23.4%), while they get proportionally more daily calories from fat compared to people with normal weight (34.3% vs 33.4%). In conclusion, our study found that amongst UK Biobank participants, adiposity (for which we used multiple measures), body mass index (BMI), waist circumference and percentage body fat, had the strongest association with total daily intake of calories and then with the absolute and percentage daily intake of fat (i.e. daily intake of fat adjusted for daily total energy intake). The association between obesity and absolute intake of sugar was less strong than other macronutrients. As a non-interventional, cross-sectional study, we could not look at the â&#x20AC;&#x2DC;sugar-fat see-sawâ&#x20AC;&#x2122;, but since we can see a low correlation between daily sugar and fat consumption (r=0.24) the participants in our study who consume diets with the most sugar tended to consume the least fat and vice versa, suggesting two distinct opposing energy sources.

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UK BIOBANK UK Biobank is a medical research project, which was set up with the aim of improving the prevention, diagnosis and treatment of a wide range of serious and life-threatening illnesses including cancer, heart diseases, stroke, diabetes, arthritis, osteoporosis, eye disorders, depression and forms of dementia. Between April 2007 and December 2010, UK Biobank recruited 502,628 participants aged between 37-69 years from the general population. Participants attended one of 22 assessment centres across England, Wales and Scotland and provided physical measures, biological samples, and detailed information about themselves and about their lifestyle. They also agreed to be followed and, since the start, participants have provided further measures, including repeated online 24-hour recall dietary questionnaires that were used in this study. For further information about UK Biobank, please visit www.ukbiobank.ac.uk/about-biobank-uk/. References: 1 Institute for Fiscal Studies 2 Briggs A et al (2013). Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study. BMJ 3 Budget. www.gov.uk/government/publications/budget-2016-documents/budget-2016#fnref:84 4 Anderson et al (2016). Adiposity among 132,479 UK Biobank participants; contribution of sugar intake vs other macronutrients. Int J Epidemiol

www.NHDmag.com November 2016 - Issue 119

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FOOD & DRINK

HARD FACTS ON SOFT DRINKS Ursula Arens Writer; Nutrition & Dietetics Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years.

Soft drink industry terms No calorie: 0 kcals / 100ml Low calorie: < 20 kcals / 100ml Mid calorie: 21-30 kcals / 100ml Regular calorie: > 30kcals / 100ml

What we drink now seems as much discussed as what we eat. Dietary surveys report food and drink diary data from population sub-groups, and these are chopped and sliced to provide great volumes of information on population nutrient intakes and trends. The latest UK National Diet and Nutrition Survey (NDNS) published in September 2016 reports that sugars intakes as a percentage of energy are unchanged in all age groups bar children aged four to 10 years: for this group there were significantly lower intakes, partly attributable to a decline in sugar-sweetened soft drinks. Intakes in children are currently 100g per day, down from 130g per day reported five years previously. Also of great use for diet detectives is data collected by market research organisations and trade associations. The best place to find most recent national data on soft drinks is the 2016 annual report of the British Soft Drink Association (BSDA). The leading statistic promoted within the report, is that sugar intake from all soft drinks consumption is down by 16% from 2012. But are we (UK public) drinking less soft drinks? Or differently? Or is product reformulation the theme? Annual per capita intakes of all types of soft drinks in the five-year period between 2010 and 2015 are slightly down, from 211 to 204 litres. In contrast, the amount spent per capita is up, from £190 to £215. So, we are drinking seven litres less per annum and/but it is costing us £25 more. The biggest sector, and nearly 40% of total sales, is anything sweet tasting and sparkling. In the five-year span ending 2015, we were drinking less fizzy drinks, but spending more on them. More than half of the 77 litres we consume annually is cola, with small trails of lemonade, tonics and other flavours. The ratio of regular calorie versus lower calorie products is about half-half. Bottled waters are a growth area, with annual intakes of nearly 40 litres, but in contrast to the sweet

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carbonates, most people (two thirds) preferred their water to be still. Fruit juice means only products with 100% fruit content. This can be chilled or ambient, as juices or smoothies, or freshly squeezed versus from concentrate. Juices are 7% of soft drinks consumed and, predictably, orange dominates over two thirds of sales. Apple limps in at just under 15% of juice sales and other single fruit juices cannot squeeze past the 5% hurdle. Juice intakes are significantly down in the five-year period to 2015, from just over 19 litres to just under 15 litres. Uniquely in the drinks sector, consumers are both drinking less and spending less on fruit juice. Perhaps the juice sector is adversely affected, because it is the one category of sweet drinks that does not have the option to exchange sugars fully, or partly, for intense sweeteners. And fruit juices are the only sector that can support claims of naturally containing useful amounts of certain vitamins and plant pigments with possible health benefits. The more specialist soft drinks sectors show opposite trends. Sports drinks are now less than 1% of drinks sales and volumes purchased over the previous five years are in decline. In contrast, the bizarre category of energy drinks is now worth two billion pounds per annum: they now claim more than 5% of drinks sales and volumes purchased are in steep growth. Unsurprisingly, most products in this sector are described as regular calorie; the small minority of energy drinks described as ‘low energy’ confuse consumers and themselves, as of course the terms are contradictory. But some of the growth of the energy drinks sector does seem to be from

Table 1: Drinks on display at the food-to-go trade show, Lunch! Barracudos: natural sugar-free energy with added proteins and vitamins Buddha Water: organic birch sap water Get More Vitamin Drinks: sugar-free vitamin drinks GoBirch Water: tree water with naturally occurring amino acids and minerals Huskara: soft drink made with outer layer of the coffee cherry Karma Cola: fair trade organic cola Impact Health Tonics: nutrient boost health tonics

MOJU: cold pressed booster shots Rejuvenation Water: amino acid enriched spring water Roots Collective: vegetable blends drinks Simplee Aloe with Superberries: detoxing aloe with antioxidant berries Tao Pure Infusion: pure tea, flower and fruit infusions ZENDO Calm + Focus: specialised nutrition anti-stress beverage

the development of the previously stronger sports drinks category. The new tax on sugar-sweetened drinks will come into force from April 2018. The first tax band will apply to drinks containing more than 5g sugars per 100ml; a second higher rate will apply to drinks containing more than 8g sugars per 100ml. There are few popular sugar-sweetened drinks containing less than 5g of sugar, although there are a few lemonade style products containing less than 8g. So for close-to-the-margin drinks, less-than-eight may be the instruction to development technologists working in the beverage sector. But some sweet drinks will not be affected by the taxation planned (fruit juice, sweetened dairy drinks). And some adults may be unaware that typical intakes of free sugars from alcoholic drinks could be higher than their intakes from fruit juices (10% vs 8% in the NDNS survey published in 2014). The issues for the soft drinks industry are the development of newer, different and perhaps also healthier products. Anything is possible, but all developments depend on consumers being willing to pay for items rather than the alternative consumer drink choices of tap water or homemade teas and coffees. Vegetable blends can boast solid nutrient contents, but will they pass the taste challenge? Coconut waters are currently popular, and claim modest health benefits, but they are

pricier and their very delicate flavours limit their appeal to some groups. Many herbal and esoteric flavoured drinks are announced, but few seem to hold out over current competition. Drinks launched at the trade foodto-go exhibition, Lunch! (September 2016) offer exotic ingredients and make vague health claims, but how many will ever hit national retailer shelving? (See Table 1.) Dietitians know that there are perfect drinks for every occasion. For daily hydration, tap water is best; tea is popular and coffee also delivers a regular dose of joy to many people. For celebration and social ease, wines and beers offer, in moderation, well-proven benefits. Juices deliver a convenient and delicious way to consume some intake of fruit and vitamins, especially C. Other sweet drinks are attractive, but need some rules. Sweet carbonates are an intense-taste pleasure, but should not be a main source of hydration, as they may contain caffeine and acidity, and may nurture the sweet-tooth, especially in children. Sports drinks perhaps, sometimes, bring benefits to people actually doing vigorous sports. And if you have been working really hard all day long on a construction site, or in a field, or on a production line, then perhaps you deserve an energy drink. Otherwise, not. www.NHDmag.com November 2016 - Issue 119

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When Calories count and so does Tolerance

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PAEDIATRIC COMMUNITY

EATING DISORDERS: IDENTIFICATION AND MANAGEMENT IN COMMUNITY SETTINGS Nikki Brierley Specialist Dietitian and CBT Therapist

Nikki has been a HCPC Registered Dietitian for eight years and more recently gained BABCP accreditation as a CBT Therapist. She currently works in a dual role within the Adult Community Eating Disorder Service at Cheshire and Wirral Partnership NHS Foundation Trust.

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

The thought of working with an individual with an eating disorder can be a challenging prospect and many healthcare professionals express a reluctance to work within this specialist area. However, with appropriate additional training and suitable clinical supervision, the possibility of making a significant positive contribution can be extremely rewarding. Eating Disorders (ED) are a group of Mental Health (MH) conditions that involve difficulties with body weight and shape. This results in abnormal attitudes towards food and causes changes to eating habits and behaviours.1,2,3 Worryingly, the incidence of ED appears to be increasing, with recent estimates as high as 725,000 individuals being affected in the UK alone.1 Although still relatively rare MH conditions, ED are associated with the highest risk of mortality and are considered complex conditions that require coordinated treatment to address the physical, psychological and social aspects.1,3 It is suggested that early identification and treatment is associated with improved outcomes, with over one half of sufferers making a full recovery and many more making significant improvements. The picture in the later stages becomes more complex and the risk of comorbidities increases. Furthermore, early treatment can reduce the risk of relapse by approximately 50%.1 Recently, ED have featured in the news/media and discussions have arisen regarding the apparent variability on service provisions across the UK, which can range from age appropriate specialist to generic/limited services. Additional funding (ÂŁ150 million) is being made available for the development of community services for children and young people,4 which will hopefully ensure improved access to appropriate treatment in the future.

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IDENTIFICATION AND ASSESSMENT

Full diagnostic criteria for ED are described within the 5th Edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and The International Classification of Disease (ICD 10, 2016). Table 1 opposite provides a brief summary of the characteristics of the main ED, alongside estimated incidence and average age of onset. The first contact with healthcare professionals (HCP) that many individuals struggling with an ED have is within a primary care setting. They may seek help directly for an ED (i.e. disclose their difficulties with body weight and shape), but many initially request help with other health concerns. Common presentations include gastrointestinal symptoms, poorly controlled diabetes, along with anxiety and depression symptoms. As such, it is possible for a non-ED specialist dietitian (or other HCP) to find themselves completing an initial assessment with an individual who may by struggling with a ED, despite asking for support with other difficulties. Table 2 overleaf provides some example cases of how individuals may present with one condition and then, after collecting additional information at assessment, the possibility of an underlying ED may be suspected. If an ED is suspected, it is important to remember that any contact is an opportunity to engage the individual

Table 1: Brief summary of characteristics of main eating disorders Diagnosis

Main characteristics

Estimated incidence

Average age of onset

Anorexia nervosa (AN)

Fear of fatness and/or drive for thinness. Persistent restriction of energy intake, leading to significantly low body weight (BMI <17.5kg/m2 in adults). Over evaluation of importance of body weight, shape or size. Restrict, binge, purge cycle of eating. Compelled to eat large amount of food in a short period of time . Some but not all the typical characteristics of AN or BN.

1 in 250 women 1 in 2,000 men

16-17, but can affect any age

2-3 times more common that AN and appears to affect mainly females (90%)

18-19, but can affect any age

Unclear, currently estimated at 5% of population Unclear Most common ED

Usually develops in later life ~30-40 years

Bulimia nervosa (BN)

Binge Eating Disorder (BED) Eating Disorder Unspecified/Eating Disorder Not Otherwise specified (EDU/EDNOS)

Any age

*Information sourced/adapted from NICE 2004, DMS - 5, ICD 10 and BEAT

with treatment, and also that >60% of sufferers wait >6 months before seeking help.1 It is advisable to initially use non-threatening questions: “Have there been any changes to your eating, appetite?” Then move onto more direct screening questions: “Do you think you have an eating problem?” and/or, “Do you worry excessively about your weight?”3 The SCOFF questionnaire was developed by researchers at St George’s Hospital Medical School and provides a simple validated and reliable screening tool to aid in the identification of and ED in >18 years. It is not a diagnostic tool, but, if an individual answer yes to two or more of the questions, it suggests an ED is likely and warrants a further investigation/comprehensive assessment. Figure 1: SCOFF questions Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone in a three-month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life?

COMMUNITY MANAGEMENT/TREATMENT

If an ED is suspected, a referral to a local specialist service is recommended. A discussion with the providers of the service will be required to obtain referral criteria/procedure. Unfortunately, as previously discussed, the availability of specialist services vary significantly depending on local service agreements and funding. Full recommendations for the management and treatment of ED are provided within NICE 2004 guidelines ‘Eating Disorders: Core interventions in the treatment and management of Anorexia Nervosa, Bulimia Nervosa and related eating disorders’. These are currently under review and publication is expected in April 2017. In summary, it is suggested that treatment requires a number of HCPs to work together in a co-ordinated manner and that individual professions should not work in isolation without appropriate support/supervision. Core professionals include psychologist, psychiatrist, nurse therapist, other therapists and dietitians. Pharmacological treatment is not considered as a first choice for ED, but may be used as an adjunct to psychological therapy, or to treat physical or co-morbid psychological conditions. Table 3 overleaf provides a brief explanation of the psychological treatment recommended for ED. www.NHDmag.com November 2016 - Issue 119

COMMUNITY Table 2: Brief case examples of possible ED presentations in a non-specialist setting* Setting General/Gastro dietetic clinic

Presenting condition IBS

Initial information

Additional information after further exploration

Commenced with IBS type symptoms. Tried changing diet to improve symptoms. Currently following FODMAP diet, with limited improvements to symptoms. Weight stable, BMI 23.5kg/m2.

Main symptom of IBS is bloating - difficult to tolerate due to perceived increase in size. Initially avoided food associated with bloating. Restricts for long periods (FODMAP aids in legitimising food restricting). Perceived binges - results in feelings of guilt/ shame and worry that weight gain will result. Exercises daily and feels guilty/unable to cope if unable to exercise. Avoids some social engagements if perceived bloating is present (fear of others judgments and feeling fat/uncomfortable). Wants to reduce weight and worried weight is increasing. Strictly following healthy eating for diabetes during the day and over eating in the evenings, including ‘naughty foods’. Feels unable to stop eating when starts eating in the evening and eats a large amount in a short period of time. Has tried to avoid having ‘naughty foods, foods in house, but if not available will go to shop a buy them. Minimises weight loss, reports not lost as much weight as people say. Denies wanting to lose weight, but states does not want to gain too much weight as considered self ‘chubby’ previously (BMI 19.0kg/m2). Not concerned about weight loss, attended due to others concerns. Expresses reluctance to increase high fat/ sugar foods in diet. Considering following a vegetarian/vegan diet.

General/Diabetes clinic

Poorly controlled Type 2 diabetes

Recent weight gain, BMI 40kg/m2. Aiming to follow healthy eating for diabetes advice but finding it difficult and requesting further support.

General/Nutrition Support clinic

Malnutrition

Recent significant weight loss (18% ~3months), BMI 16.7kg/m2. Poor appetite. Further medical investigations planned (NAD to date). Family expressed concerned about weight loss.

*Please note these are illustrative examples only

THE ROLE OF THE DIETITIAN

Considering that nutritional difficulties can be a major symptom of ED, and changing eating behaviours a significant part of recovery, it is clear to see how the considerable nutritional knowledge and skills of a dietitian can make an obvious contribution to treatment. However, it is also essential to understand and accept that dietary difficulties are a symptom of an underlying MH condition and, as such, dietary intervention alone is not suitable and could indivertibly cause harm. A dietitian is best placed to make a positive contribution as a part of a suitably qualified, 16

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trained, supervised and experienced MDT, allowing a collaborative environment and ensuring well-planned and considered interventions. To ensure safe practice, it is recommended that dietitians working with individuals with ED have completed additional appropriate training and receive clinical supervision from a suitably experienced Dietitian. The British Dietetic Association (BDA) MH ED sub group provides recommendations on training and supervision and this information can be obtained from www.dietitiansmentalhealthgroup.org.uk/ eating-disorders/. If in a non-ED specialist setting, the dietitian’s role may be identification, engagement and

Table 3: Psychological therapies and ED Psychological therapy

Description

Evidence

Cognitive Behavioural Therapy (CBT)

Psychotherapy that examines how beliefs and thoughts are linked to behaviours

Researched supports efficacy as treatment of ED 1st line treatment for BN, BED and EDOS/EDU Limited research for use with AN

Interpersonal Therapy (IPT)

Psychotherapy that examines how illnesses can be triggered by events involving relationships with others

Some research for efficacy as treatment of ED

Cognitive Analytic Therapy (CAT)

Uses methods from psychodynamic and CBT, examines how behaviours cause problems

Considered in complex cases

Dialectical Behaviour Therapy (DBT)

Based on CBT, but adapted for individuals who experience emotions very intensely

Considered in complex cases and where self-harm is evident

suitable onward referral, ensuring adequate information is provided to allow the specialist services to identify whether the individual is suitable for service. What is vitally important at this stage is that the individual feels heard, understood and encouraged to engage in treatment, thus an empathic, supportive and reassuring approach is needed. Initially, it is common for those experiencing an ED to be ambivalent about their symptoms and/or behaviours; it is essential, therefore, that any HCP working with a patient at this time is accepting of this, so that they are able to explore further. To gain more knowledge and experience of ED, it may be beneficial to consider membership of the BDA ED specialist group, which offers some online resources and regular meetings. It may also be advantageous to approach a specialist ED services and enquire about shadowing opportunities; of particular value would be attending MDT meetings to observe assessment/diagnosis discussions and care planning. As previously mentioned, additional funding is being made available for the development of ED services and, thus, an increase in career opportunities within ED is currently occurring. Working within community ED service provides an exceptional opportunity to work as part of an MDT and to make a genuine contribution to the enhancement of individualsâ&#x20AC;&#x2122; quality of life.

SUMMARY

ED are complex and require a MDT approach. Nutritional difficulties are a symptom of the illness and although symptom management can be extremely beneficial, psychological support is also needed to address the underlying MH condition. Individuals suffering with an ED may present directly or indirectly when seeking support and often wait >6 months before asking for help. Commonly, GI disturbances and poorly controlled diabetes may be first presentation in a primary care setting. A dietitian may be best placed to identify a suspected ED and given that early treatment appears to be an important factor of successful treatment, an awareness of how to screen for ED whilst positively engaging the individual may prove vital in enhancing overall treatment outcomes. In addition to identification, a dietitianâ&#x20AC;&#x2122;s role may involve working directly with the individual struggling with an ED; this is best done as part of an MDT, with relevant training and suitable clinical supervision. Recent increases in funding are resulting in increased career opportunities within ED, providing an excellent opportunity to join this challenging and extremely rewarding specialism. Further knowledge and experience can be gained by accessing the available resources, completing additional training and/ or making links with specialist ED services. www.NHDmag.com November 2016 - Issue 119

BREASTFEEDING IS BEST FOR BABIES

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Discover more at hipp4hcps.co.uk 1 Contains 1.89g/100kcal of protein, including α-lactalbumin, making the protein level and quality closer to that found in breastmilk (1.7g/100kcal). Nommsen LA et al. Am J Clin Nutr 1991; 53: 457–465. 2 Koletzko B et al. Am J Clin Nutr 2009; 89(5):1502S–8S. 3 Price per 100g of infant milk powder: HiPP £1.06, Aptamil £1.11. Price per case of 24 infant milk hospital formula: HiPP £8.36, Aptamil £8.84. Prices correct as of May 2016. Important Notice: Breastfeeding is best for babies. Breastmilk provides babies with the best source of nourishment. Infant formula milks and follow on milks are intended to be used when babies cannot be breastfed. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle feeding may reduce breastmilk supply. The financial benefits of breastfeeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Infant formula and follow on milks should be used only on the advice of a healthcare professional.

PAEDIATRIC

Jacqui Lowdon Paediatric Dietitian - Team Leader Critical Care, Therapy & Dietetics, RMCH Presently team leader for Critical Care and Burns, Jacqui previously specialised in gastroenterology and cystic fibrosis. Although her career to date has focused on the acute sector, Jacqui has a great interest in paediatric public health.

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

FOLLOW-ON FORMULA: WHEN COMPLEMENTARY FEEDING REQUIRES SUPPLEMENTING The benefits of exclusive breastfeeding are well documented,1,2 with the percentage of newborns initially breastfed rising.3 However, few UK mothers still exclusively breastfeed for the first six months of their infants life.3 Here, Jacqui Lowdon updates us on current guidelines and provides us with a case study on infant feeding difficulties. The last Infant Feeding Survey (IFS), 2010,3 demonstrated that the initial breastfeeding rate in the UK had increased from 69% in 2000 to 76% in 2005 and finally to 81% in 2010, and that mothers are continuing to breastfeed for longer. Nevertheless, the proportion following current guidelines on exclusively breastfeeding for the first six months of a baby’s life have remained low since 2005, with only one in a 100 mothers following this guideline. Table 1 overleaf shows a breakdown within the UK of the percentage of newborn babies initially breastfed, between 2005 and 2010. It is, therefore, essential that continuous improvements are made to infant formulas (IF), ensuring that the high nutrient requirements of infants are to be met, if mothers are unable to or choose not to breastfeed. GUIDANCE AND REGULATIONS

The most recent definition4 of followon formula milk (FOFM) states that it is ‘food intended for use by infants when appropriate complementary feeding is introduced and which constitutes the principal liquid element in a progressively diversified diet of such infants’. FOFM contains the same ingredients as standard IF, but with higher levels of protein, iron and micronutrients, such as vitamin D. The levels of nutrients are strictly controlled

under the European Commission Directive on infant formulae and follow-on formulae. The Codex Alimentarius of the United Nations Food and Agriculture Organisation and the WHO also provides guidance on the composition of IF, which is used widely internationally (Codex Alimentarius Committee, 2006). The most recent UK legislation was 2007, with amendments made since. In 2014 the EFSA produced its opinion on the essential composition of infant and follow-on formulae.5 In July 2016, Regulation (EU) No 609/2013 (commonly referred to as the Food for Specific Groups Regulation or FSGs) replaced the Directive 2009/39/EC on foodstuffs intended for particular nutritional uses (PARNUTS). The FSGs Regulation abolishes the concept of dietetic foods and provides a new framework, establishing general provisions for a limited number of well-established and defined categories of food that are considered as being essential for certain vulnerable groups of the population, one of which is the category for IF and FOFM. Directive 2006/141/EC (infant formulae and follow-on formulae) will be replaced by Regulation (EU) 2016/127 in February 2020, with a longer transitional period for IF and FOFM manufactured from protein hydrolysates, due in 2021. www.NHDmag.com November 2016 - Issue 119

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Table 1: UK percentage of newborn babies initially breastfed, 2005-2010 Between 2005 and 2010, the percentage of newborn babies initially breastfed rose from: 78% to 83% in England 67% to 71% in Wales 70% to 74% in Scotland 63% to 64% in Northern Ireland CASE STUDY: INFANT FEEDING DIFFICULTIES 1 Assessment Ellie was born at term, on the C25th-50th for weight and length. Mum tried initially to breastfeed, but developed mastitis and found it difficult to continue. So, at 10 weeks of age, Ellie was placed onto a standard infant formula. Like most infants, Ellie lost weight after birth initially, whilst full feeding was being gradually established. The majority of infants regain their birth weight by day 10-14th of life. NICE (The National Institute for Health and Care Excellence,6 recommends that babies are weighed at birth and in the first week of life, followed up at weeks eight, 12 and 16 and again at one year of age. However, Ellie did not regain this lost weight which was attributed to the difficulties that mum was experiencing whilst breastfeeding. The stress of Ellie not gaining weight also contributed to mum’s poor experience of breastfeeding and one of the reasons why mum decided to place Ellie onto a formula feed. At eight weeks of age, prior to commencing the formula, Ellie’s weight had fallen towards the C2nd. As mum was unsure how much formula to feed, she was advised by the health visitor that bottle fed babies should be fed on demand, as with breastfed babies and that they should not be encouraged to ‘finish the bottle’. Breastfed babies can regulate their own intake of milk. A systematic review7 of the volumes taken of breast milk and infant formula in early infancy have shown that formula fed infants have a higher intake than breastfed babies. Not only did bottle fed babies take larger volumes, but they also had more energy dense milk. Based on this evidence, Ellie should have started to thrive. However, initially, Ellie did not take to the formula, but mum persevered and eventually Ellie started to take formula from a bottle. At this stage she was taking around 120-130mls/kg and although this is less than the needs of most babies at this age (150mls-180mls/kg), by week 16, Ellie’s weight gain had started to show an improvement, increasing towards C9th. Whilst Ellie continued to be fed with the standard formula, she remained a small feeder, never taking more than 130mls/kg. Her weight showed an initial improvement, increasing to the C9th but never increasing higher than this. www.NHDmag.com November 2016 - Issue 119

PAEDIATRIC 2 Identification of nutrition and dietetic diagnosis At around 20 weeks of age (five months) mum introduced Ellie to some solid food, initially fruit and vegetables. However, mum noticed that Ellie’s intake of formula milk declined, taking less than 120mls/kg. At this stage, Ellie was approaching six months of age and her weight gain had started to slow down again. Ellie was slow to take a wide variety of solids and mum found it difficult to progress with different flavours and lumps. Concerned, she took Ellie to the GP who diagnosed iron deficiency anaemia and was referred to a community paediatric dietitian for dietary advice. The paediatric dietitian suggested to mum that, as Ellie was now six months of age, she change her onto a follow-on formula milk. Mum had always been informed that FOFM were unnecessary by her health professionals. Presently, there is no evidence to support the use of FOFM in infants receiving complementary foods containing adequate protein, carbohydrate, fat and iron.8 The Scientific Advisory Committee on Nutrition9 stated that ‘there is no published evidence that the use of any follow-on formula offers any nutritional or health advantage over the use of whey-based infant formula among infants artificially fed’. In 2013, the WHO reiterated its position10 that FOFM is not necessary and is unsuitable as a replacement for breast milk after six months. For this reason FOFM is not included in the UK Healthy Start Scheme. However, FOFM does have characteristics that may be of benefit for certain groups of babies and children. 3 Plan and implement nutrition and dietetic intervention It is suggested that FOFM is given from six months of age, when an infant’s iron stores are depleted and cannot be replaced by breast milk (being a poor source of iron). However, randomised controlled trials have not shown any consistent benefit from the additional iron in FOFM compared to IF, after the age of six months.11 A position paper by ESPGHAN12 has recommend that FOFM should be iron-fortified, but that there is insufficient evidence to determine an optimal iron concentration. Further studies are required of different iron fortification levels of FOFM. There is some argument that FOFM should be considered for inclusion in anaemia prevention programmes, especially aimed at the lower socio-economic families in the UK,13 although meat-rich weaning diets and use of commercially prepared baby foods, which are iron supplemented, are also advantageous.14 Other minerals FOFM contains higher amounts of calcium and phosphorous because calcium requirement increases in the second six months of life. Infants should begin to consume solid foods at six months and, therefore, additional calcium and phosphorus requirements should be met without difficulty from first IF and food sources.23 Protein When complementary feeding, the most suitable protein-to-energy ratio in a formula depends on the proteinto-energy ratio of the food available. This will obviously vary, on what is available. The protein-to-energy ratio of complementary food in many developed countries is high, up to 2.5 g/100 kcal.15 A very high protein milk is, therefore, not needed to achieve adequate intakes. However, even modest displacement of breast milk, or standard formula milk, by low-protein complementary foods can result in inadequate total protein intake. An alternative approach to meeting protein needs in situations where complementary foods contain no or low amounts of protein, the possible use of a FOFM, containing more protein,16 may help. 5 Monitor and review At two months follow-up, although Ellie was consuming the same volume of formula, her weight gain had improved and was now heading up towards the C25th. This was attributed to the improvement in iron intake and improved protein intake from the FOFM. The Scientific Advisory Committee on Nutrition17 states that: ‘there is no published evidence that the use of any follow-on formula offers any nutritional or health advantage over the use of whey-based infant formula among infants artificially fed’. From a nutritional point of view, it maybe that FOFM is best considered in relation to the introduction of complementary food and the toddler diet, rather than breast/bottle feeding.

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PAEDIATRIC

From a nutritional point of view, it maybe that FOFM is best considered in relation to the introduction of complementary food and the toddler diet, rather than breast/bottle feeding. 4 Evaluation The 2010 IFS18 investigated the use of FOFM at different stages. At Stage 2 of the survey (four to 10 weeks old), use was low (9%). By Stage 3 (eight to 10 months old), mothers were more likely to be using FOFM (57%) as their baby’s main source of milk at 35%. At Stage 3, 69% of all mothers had given their baby FOFM. Most mothers followed the recommendation of not giving their baby FOFM before the age of six months (16% had given FOFM when their baby was four months old, increasing to 50% at six months). Mothers from routine and manual occupations and mothers who had never worked were more likely than average to say that they had given their baby FOFM at an earlier age (18% and 27% respectively at four months). Protein needs are met by breast or formula milk protein, but at the time of weaning, the most suitable protein-to-energy ratio in a milk or formula will depend on the protein-to-energy ratio of the weaning foods available. This will obviously vary depending on what is offered and what is available. The protein-to-energy ratio of weaning food in many developed countries is high, reaching 2.5g/100kcal after correction for protein quality.19 Thus, a very-high-protein milk is not needed to achieve satisfactory intakes. However, even modest displacement of breast milk or standard formula milk by low-protein complementary foods can result in inadequate total protein intake. In many developing countries, the only weaning food is maize or rice, which has a low protein-to-energy ratio. When the protein concentration of the weaning food drops below that of milk, i.e. when it is <1g/100kcal (such as for cassava), it is impossible to meet total protein needs. An alternative approach to meeting protein needs in situations where complementary foods contain no or low amounts of protein, is the possible use of a FOFM containing more protein.20 CONCLUSION

The growth and development of infants fed with FOFM require to be similar to those infants who continue to be breastfed while complementary food is introduced. During the first year of life, Stage 1 infant formulas can be consumed by babies to help meet their nutritional requirements. The recent EFSA Panel has concluded that it is not necessary to propose specific compositional criteria for formula consumed after one year of age. Presently, there is no evidence to support the use of FOFM in infants receiving complementary foods containing adequate protein, carbohydrate, fat and iron.21 The Scientific Advisory Committee on Nutrition22 stated: ‘There is no published evidence that the use of any follow-on formula offers any nutritional or health advantage over the use of whey-based infant formula among infants artificially fed.’ There may be nutritional and health advantages to continuing formula milk intake into the second year for those infants considered 24

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at high risk of iron deficiency due to poor diet or other difficulties, such as fussy/faddy eating. It is advised, however, that first formula remains the milk of choice during the first year if babies are not breastfed.21 From a nutritional point of view, it maybe that FOFM is best considered in relation to the introduction of complementary food and the toddler diet, rather than breast/ bottle feeding. The medical literature now contains mixed findings on the use of FOFM when included in the introduction of solids for prevention of iron deficiency anaemia in babies over six months of age and in toddlers. With the ‘growth acceleration hypothesis’ suggesting that early and rapid growth during infancy programs the infant metabolic profile to be susceptible to obesity and the other components of metabolic syndrome, a review of the protein content of FOFM is quite timely and will lead manufacturers to review their formulations.

CONDITIONS & DISORDERS

CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND THE OBESE PATIENT Anne Wright Registered Dietitian and Freelance, AM Dietetics

Chronic Obstructive Pulmonary Disease (COPD) is a serious long-term lung disease in which the flow of air into the lungs is gradually reduced by inflammation of the air passages and damage to the lung tissue. Chronic Bronchitis and emphysema are common types of COPD. It is a complex multi system disease with multiple comorbidities and clinical problems.

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

Issues include poor health status, frequent exacerbations and decreased physical activity. According to NHS England, it is the fifth biggest killer in the UK. Figures show that people living with a COPD diagnosis are mostly over the age of 40. The proportion of people living with COPD increases markedly with advancing age. Many dietitians have had the experience of running COPD groups and programmes, with a significant number doing so in the early stages of their careers, or in general community work. Often, these groups contain a complex mix of patients from early to later stages of the disease condition. This can cause some challenges when planning and targeting these programs, due to the changing dietary needs throughout the disease progression. For patients with COPD and other chronic lung conditions, maintaining a healthy lifestyle is crucial for managing their condition and improving symptoms. COPD has typically been considered a disease associated with malnutrition, low body weight and reduced skeletal muscle mass. Patients are at risk of malnutrition as the disease progresses.1 Cachexia is known to be a deteriorating factor for survival of patients with COPD, and treatment guidelines around nutrition screening and nutritional support are in place, but data and treatment guidelines related to COPD and obesity are limited.2 Obesity, however, is becoming more common in

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COPD with a prevalence that is higher than the general population.3 THE IMPACT OF OBESITY

The role obesity plays in COPD is of important significance. Although obesity is not necessarily a risk factor for chronic respiratory diseases like COPD, there is clinical evidence that suggests an increasing influential relationship between the two.4 COPD itself has a major adverse impact on patientsâ&#x20AC;&#x2122; exercise capacity, health status and mortality. When COPD and obesity coexist, patients suffer an addition burden. Obesity lends itself to a worsening of COPD symptoms and a decrease in both exercise tolerance and quality of life. Ventilation refers to breathing, or the inhalation and exhalation of air from the lungs. An overabundance of fat tissue, which occurs from obesity, impairs the breathing process in both adults and children. Moreover, an increased BMI is also associated with a host of other respiratory problems, including a reduction in the following pulmonary function tests such as total lung capacity, functional residual capacity and forced vital capacity (FVC). Since carrying around excess weight increases the work of breathing, there is a direct association between obesity and shortness of breath, or dyspnoea, which is also recognised as the hallmark symptom of COPD. When COPD is coupled with obesity, COPD symptoms, namely dyspnoea, worsen. www.NHDmag.com November 2016 - Issue 119

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CONDITIONS & DISORDERS

Despite obesity being an established risk factor for poor health outcomes, paradoxically in COPD, it has been associated with improved survival and lung function. A recent multicentre prospective cohort study5 conducted in the United States, showed obesity was prevalent among their population with COPD and was associated with worse COPD-related outcomes, ranging from quality of life and dyspnoea to restricted abilities to walk short distances and greater odds of experiencing acute exacerbations. These associations were strengthened when obesity was analysed as a dose-dependent response. Obesity in patients with COPD may contribute to a worse COPDrelated course. THE OBESITY PARADOX

Despite obesity being an established risk factor for poor health outcomes, paradoxically in COPD, it has been associated with improved survival and lung function. In fact, mild to moderate obesity has been associated with improved survival, improved lung function and reduced hospital admission.6 In the epidemiological Copenhagen City Heart Study, obesity was associated with a 20%-34% increase in the relative risk (RR) of all-cause mortality in patients with mild-to-moderate COPD compared to normal BMI patients with comparable disease severity.6 Obesity in patients hospitalised for COPD has also been shown to be associated with substantially reduced in-hospital mortality risk and the possibility of early re-admittance in retrospective chart reviews.7 This obesity paradox in COPD may be explained by a few factors. Overweight or obese patients with COPD may receive medical attention earlier (i.e. while having

better preserved expiratory flows and less hyperinflation compared with their lean counterparts). Peak oxygen consumption (VO2) has been found to be higher in obese patients with COPD than in their normal‐BMI counterparts. Obese patients with COPD may not only have more adipose tissue, but more muscle, offering a survival advantage.8 A 2014 study9 looked at the potential mechanisms behind the obesity paradox in COPD. Fat accumulation did not explain the link, but the study identified that two variables: muscle mass and exercise capacity, were both preserved in heavier patients. In fact, for COPD patients, increasing BMI may reflect higher fitness levels, greater metabolic reserve and less cachexia.10 Muscle mass is a key feature for COPD patients. The question of the obesity paradox is still being examined. A 2016 dose response metaanalysis,11 examining body mass indexes and mortality in COPD, found a significant nonlinear relationship between BMI and mortality of COPD patients. COPD patients with BMI of <21.75 kg/ m2 had a higher risk of death. Moreover, an increase in the BMI resulted in a decrease in the risk of death. The risk of death was lowest when BMI was 25-30 kg/m2. The BMI was not, however, associated with all-cause mortality when BMI was >32 kg/m2. The study findings indicated that overweight is associated with a lower risk of all-cause mortality among patients with COPD, whereas underweight is associated with a higher risk of all-cause mortality in these patients. However, there was limited evidence to support www.NHDmag.com November 2016 - Issue 119

MY COPD MEANS MY APPETITE HASNâ&#x20AC;&#x2122;T BEEN VERY GOOD...

CONDITIONS & DISORDERS the association between obesity and the risk of allcause mortality in patients with COPD. These findings and possible mechanisms to explain the obesity paradox suggest that there is much more to it than weight alone. This creates a conundrum for clinicians - we see people who need to lose weight to reduce their risk of other chronic diseases, but we don’t know the effect that this has on COPD outcomes. MANAGING WEIGHT IN COPD PATIENTS WITH A HIGHER BMI

The optimal management approaches to obesity and COPD are unknown; there are no evidencedbased recommendations for obese COPD management. Consideration of all factors must be taken into account, carefully weighing up evidence supporting weight loss to improve quality of life, lung function and exercise capacity with that supporting maintenance of weight for long-term survival. Despite this, many clinicians encourage obese patients to reduce their weight. This may be deleterious, depending on the method taken, because weight-loss interventions can reduce both fat and muscle mass. Hence, any intervention for obese COPD individuals must aim to preserve muscle mass.12 Eating plans should meet core nutritional requirements and limit exposure to foods that may cause inflammation. A recent pilot study from the University of Newcastle12 has looked into incorporating weight loss regimes for obese COPD patients which maintain muscle mass. Patients were offered a calorie-controlled diet with meal replacement therapy and nutritional counselling, in addition to a resistance exercise training program delivered by a physiotherapist. The majority of trial participants had moderate to severe disease COPD. After 12 weeks, they had achieved an average weight loss of 6% and significant fat reduction without compromising muscle composition. Around 70% achieved a clinically significant improvement in their health status. Participants achieved major quality of life improvements. They improved their exercise capacity, a real predictor of COPD mortality, and they became stronger. This suggests that, at least for short term outcomes, weight loss interventions could lead to improved COPD outcomes which oppose the obesity paradox.

Suggested strategies for obese and overweight COPD patients: • Overweight and obese patients should be supported individually, or, in the case of group programs, in their own groups and not included in mixed groups with later stage or underweight patients. • Patients should be part of the screening protocols in place for all COPD patients and should be monitored for changes in circumstances that may be associated with disease progression (including breathing issues, appetite changes, functional changes, fatigues, chewing or swallowing difficulties). • COPD patients with a BMI >32Kg/m2 should be considered for weight loss in order to improve symptoms and quality of life. • Patients who are overweight, but with BMI <32Kg/m2, should be managed using a weight maintenance focus whilst using treatment outcome measures, such as diet quality, respiratory and exertion measures and other quality of life indices. • Dietary advice should follow balanced diet recommendations using the DOH eat well plate model, counselling models and portion guides. • Dietary advice should include advice on potential ‘at risk’ nutrients and nutrients of importance in COPD, such as adequate protein, omega-3 fats, vitamin D and calcium. • Weight loss goals should be achieved at a slow rate with a goals negotiated around 5-10% body fat loss or to achieve a BMI <32Kg/m2. • Weight reduction must be combined with resistance exercises designed to maintain muscle mass.

www.NHDmag.com November 2016 - Issue 119

Getting Nan back to her old tricks again!

is a powdered, neutral-tasting carbohydrate loading drink mix for the pre-operative dietary management of patients undergoing surgery. has been shown An Enhanced Recovery Programme including the use of to significantly reduce post-operative hospital stay with a return towards earlier gut function when compared with fasting or supplementary water.1 Helping patients get back to doing the things that they enjoy sooner.

Preload™ is a Food for Special Medical Purposes and must be used under strict medical supervision. 1. Noblett S, Watson D, Huong H, Davidson B, Hainsworth P, Horgan A (2006) Pre-operative oral carbohydrate loading in colorectal surgery: A randomized controlled trial. Colorectal Disease: 8, 563-569.

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IN ASSOCIATION WITH THE BSNA

CLINICAL

ENHANCED RECOVERY AFTER SURGERY: THE ROLE OF NUTRITION Naomi Johnson Scientific and Regulatory Manager at the British Specialist Nutrition Association Naomi has a First Class Honours degree in Nutritional Science and an MSc in Public Health Nutrition. She has worked in the nutrition industry for several years. www.bsna.co.uk

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

For any patient undergoing surgery, recovery and avoidance of complications are key objectives. The pre-and post-operative health of the patient is an integral part of this. Patients who present for surgery with undernutrition have a higher risk of post-operative complications including morbidity and mortality.1,2 Adopted by a number of hospitals, enhanced recovery after surgery (ERAS) protocols have become a widely accepted toolkit.3 These guidelines provide evidence-based recommendations for oral nutritional supplements (ONS) and enteral nutrition (EN) in surgical patients.4 In a systematic review of six trials (three RCTs and two CTs; n=512), use of ERAS resulted in reduced hospital stays and a lower morbidity rate (RR: 0.54 [CI 0.421.69]), although there was no difference in readmission and mortality rate. The ERAS guidelines seek to minimise surgical stress, maintain nutritional status, reduce complications and optimise recovery rates. The ERAS programme considers key nutritional and metabolic aspects of pre- and postoperative care, which integrate nutrition into the overall management of the patient, and include the following: • Pre-operative nutrition5 • Avoidance of long periods of preoperative fasting5 • Fluid intake and carbohydrate loading up to two hours preoperatively5 • Re-establishment of oral feeding as early as possible after surgery (ideally the first post-operative day)5 • Metabolic control, e.g. of blood glucose5 • Reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function4 Standardised analgesic and aesthetic regimens and early mobilisation are also acknowledged.4

Recently published European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on nutrition in cancer patients strongly recommend that all cancer patients undergoing either curative or palliative surgery are managed using an ERAS programme.5 More than three million people in the UK are malnourished at any one time, with an estimated 30% of people admitted to acute hospitals and care homes at risk of malnourishment.6,7 A survey by the British Association for Parenteral and Enteral Nutrition (BAPEN) of UK hospitals found that adults admitted to hospital were more underweight (<20kg/m2) when compared with the general population.2,7 Guidance from ESPEN recommends that nutrition support should be used in patients with severe nutritional risk 10-14 days prior to surgery;4 inadequate oral intake during this period is associated with a higher mortality.4 For those patients at severe nutritional risk, a delay to surgery and administration of tube feeding and/ or ONS is advised (with exception to intestinal obstruction, severe shock and intestinal ischemia). Use of tube feeding and/or ONS is also indicated in those patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days and those who will be unable to eat for more than seven days perioperatively (even if undernutrition is not obvious). Parenteral nutrition (PN) is indicated in patients for whom EN www.NHDmag.com November 2016 - Issue 119

CLINICAL

Enhanced recovery after surgery programmes can have a measured clinical impact on overall patient outcomes; however, the integration of this knowledge into practice is varied across the UK.

may not be appropriate, such as in intestinal obstruction or failure.4 PN can also be used to complement EN, in those patients consuming <60% of calorific requirements. In upper GI cancer patients at severe nutritional risk, use of PN pre-operatively reduced complications.8 PRE-OPERATIVE NUTRITIONAL CONSIDERATIONS

Once a common practice, pre-operative fasting is now considered unnecessary for most patients (although this is contraindicated in those at risk of aspiration) and is even associated with delayed recovery. An interruption in nutritional intake can be negatively implicated in health outcomes; increased metabolic stress, hyperglycaemia and insulin resistance are all indicated in pre-operative fasting.4,9 When an earlier return to gastrointestinal function is facilitated, patients’ tolerance to normal food and even enteral feeding can also be improved.10 In a systematic review of patients who had elective gastrointestinal surgery, septic complications and length of hospital stay were reduced in those who received early EN.11 It should be noted, however, that risks are associated with both enteral feeding and its early use. BAPEN guidelines provide advice on best practice for the administration of medication via enteral tubes.12 In a prospective non-randomised study, significant reductions in nosocomial infections and overall complications were shown in 32

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high-risk surgery patients (NRS 2002 ≥5) who received sufficient pre-operative nutrition therapy (>10kcal/kg/d for seven days) when compared with patients who received insufficient therapy.13 For low risk patients, no differences were observed between sufficient and insufficient EN.13 ‘Immune modulating nutrition’ or ‘immunonutrition’ (a liquid nutritional supplement enriched with specific nutrients) given by the oral/enteral route during the peri-operative period has demonstrated a reduction in post-operative infective complications.14 Optimal rehabilitation and wound healing is dependent on the body being in an anabolic state.4 For the majority of patients undergoing surgery, a pre-operative carbohydrate drink the night before (800ml) and a 400ml drink two hours prior to anaesthesia is generally advised.4 Reduced post-operative insulin resistance and preservation of skeletal muscle mass has been demonstrated in colorectal patients and those with hip replacement who took a 12.5% hypo-osmolar carbohydrate rich drink preoperatively.15,16,17,18 Additionally, pre-operative carbohydrate loading reduces thirst, hunger and anxiety.17,18 The correct pre-operative preparation is essential to post-operative recovery; carbohydrate loading reduces insulin resistance and diminishes nitrogen and protein loss.19,20 Post-operatively it also helps to preserve skeletal muscle.

The overall health and nutrition status of the patient prior to surgery will vary significantly. Underweight, malnutrition and low muscle mass may already be present pre-surgery due to aging (sarcopenia), disease (cachexia) and inactivity (atrophy). As with any surgery, a level of stress is placed on the body, resulting in immune system suppression and a rise in stress hormones and inflammatory markers. Insulin resistance is a sign of surgical stress, with more extensive surgery associated with greater levels of insulin resistance - an independent risk factor that influences length of stay and poor wound healing.21 Post-operative control of blood sugar levels is, therefore, essential to recovery and overall outcomes. The overall health and nutrition status of the patient prior to surgery will vary significantly. Underweight, malnutrition and low muscle mass may already be present presurgery due to aging (sarcopenia), disease (cachexia) and inactivity (atrophy).22 Surgical nutrition studies have identified weight loss (>10%) and low albumin (<30g/l) as risk factors for adverse outcomes.23 Skeletal muscle plays an essential role in health; loss of aerobic capacity, reduced strength, weakness, fatigue, insulin resistance, falls and fear of falling, frailty disability and mortality are all associated with skeletal muscle loss.24 During periods of inactivity/immobility, such as post-surgery, a loss of lean body mass is observed, a factor which is further impaired with increasing age, as the bodyâ&#x20AC;&#x2122;s ability to recover after surgery is diminished. An older cohort subjected to 10 days of inactivity, experienced approximately a three-fold greater loss of lean leg muscle mass when compared to a younger cohort examining protein synthesis and muscle mass in healthy adults who were subjected to bed rest for 28 days. 25,26 From age 40, muscles do not respond as well to protein from the diet as that of younger counterparts. 27 The right nutrition for muscle health and recovery is, therefore, key.

POST-OPERATIVE NUTRITIONAL CONSIDERATIONS

Post-operatively, for the majority of patients, a standard whole protein formula is appropriate which may include immune-modulating substrates (arginine, omega-3 fatty acids and nucleotides) in enteral form.4 Extensive research exists on the role of ONS in older populations, which has shown to increase both body weight and improve nutritional status.28 In those older individuals who are malnourished, an ONS high in protein, and vitamin D in particular, can have a valuable role to play in improved recovery. Patients with whole-body protein depletion have been shown to have a marked increase in both major complications and duration of postoperative stay.29 For both young and elderly individuals it is well researched that moderate-tolarge servings of protein or amino acids increases muscle protein synthesis.30,31 In older adults, high doses of protein (>25g) or essential amino acids (10-15g) have a similar ability to synthesise muscle protein compared to younger ones; lower doses (protein <20g; EAAs <8g) do not achieve the same skeletal muscle response. However, single servings of >30g protein do not stimulate a greater anabolic response between younger and older adults.32 ASPEN has suggested 1.2-2.0g protein/kg for those in the critical care setting, including post-operative major surgery.33 Enhanced recovery after surgery programmes can have a measured clinical impact on overall patient outcomes; however, the integration of this knowledge into practice is varied across the UK. A key driver in its successful adoption is the patient, and management of their expectations. Successful adoption of an enhanced recovery approach also requires input from the multidisciplinary team; â&#x20AC;&#x2DC;enhanced recovery is about the whole team rather than an individualâ&#x20AC;&#x2122; at a sustained level.34 www.NHDmag.com November 2016 - Issue 119

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CONDITIONS & DISORDERS

COELIAC DISEASE AND BONE HEALTH IN ADULTS Ali Hutton Registered Dietitian, Vitaflo International

Ali works as a Dietitian in Medical Affairs and Marketing at Vitaflo International.

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

Coeliac disease (CD) is an autoimmune disorder caused by an adverse reaction in the small intestine to dietary gluten from wheat, rye, and barley.1 Screening studies suggest that the prevalence of CD varies from 1-2% in first world populations, but most cases (an estimated 75-90%) do not receive a clinical diagnosis.2 CD affects at least one in 100 people in the UK and in Europe, but only about 24% of people with the condition are clinically diagnosed.3 In addition to gluteninduced small intestinal mucosal lesions, CD can have skin, neurological and other extra-intestinal manifestations.4 It is associated with metabolic bone disorders including osteoporosis, osteopaenia5 and osteomalacia.2,6 Osteoporosis is a skeletal disorder characterised by low bone mineral density (BMD) and micro-architectural deterioration of the skeleton,7 with a consequent increase in bone fragility and susceptibility to fracture.8 Primary osteoporosis occurs in the absence of an underlying disease, whilst secondary osteoporosis occurs due to the effect of certain medications, or in the presence of an underlying disease such as CD.7 It is important to elucidate secondary causes of osteoporosis as the treatment of these patients may differ and its response to treatment may be limited if the underlying disorder is unrecognised and left untreated.7 Management of osteoporosis includes advice on regular physical activity, reducing smoking and alcohol consumption, ensuring a health body mass index (BMI) and calcium and vitamin D supplementation where appropriate.9 People with CD who have successfully adopted a glutenfree diet (GFD) need to follow these basic strategies to reduce the risk of developing bone disease.10,11 Calcium supplementation may prevent bone

loss in older men and women, but there is no convincing evidence that it decreases the risk of fracture in patients with osteoporosis.12 Drug treatments are, therefore, usually necessary and include bisphosphonates, teriparatide, raloxifene and calcitonin.12 Osteopenia is a condition in which BMD is lower than normal, but not low enough to be classed as osteoporosis. In some cases, it is a precursor to osteoporosis. Osteomalacia results from bone demineralisation. It is caused by vitamin D deficiency and leads to softening of the bone. The increased risk of bone fracture associated with these conditions has an important impact on a patientâ&#x20AC;&#x2122;s activities of daily living and the ability to work.2 SCREENING AND DIAGNOSIS

If undiagnosed and left untreated, CD can lead to problems such as anaemia,11 unexplained infertility problems, nutritional deficiencies,3 osteoporosis5,9 and osteopenia.5 Early diagnosis and strict adherence to a gluten-free diet (GFD) are both indicated in improving BMD,11,13,14 although some studies have shown that those with CD still have lower than average bone density despite following a strict GFD.11 McFarlane et al in 199510 noted that the largest gains in BMD were detected in the most recently diagnosed patients, suggesting that there is a reversible component to the osteopenia present at the time of diagnosis of CD and that this can be improved by treatment with www.NHDmag.com November 2016 - Issue 119

CONDITIONS & DISORDERS

NHS data indicates that the cost of treating osteoporosis in those with CD may lie somewhere between £2.3 million and £21.3 million per year.

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www.wellfoods.co.uk 36

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a GFD. However, one population-based study found a similar excess risk of fractures before and after CD diagnosis and commencement of a GFD (i.e. incidence ratios five to 10 years before and after CD diagnosis were 1.8 and 2.2 respectively).10 A study by Valdimarsson et al in 199516 found that subjects without diarrhoea or weight loss had osteopenia to the same degree as subjects with these symptoms. Similarly, Molteni et al 199017 found no correlation between osteopenia and severity of symptoms, suggesting that screening for CD is indicated in all adult patients with osteoporosis or osteopenia.16 Screening for CD should be carried out in highrisk groups such as those with iron deficiency anaemia, Down’s syndrome, Type 1 diabetes mellitus and osteoporosis,15 especially in those with very low T-scores or multiple osteoporotic fractures.18 Unfortunately, the average length of time taken for someone to be diagnosed with CD from the onset of symptoms is a staggering 13 years.3 Clinicians must be made aware of the potential extra-intestinal manifestations of CD to avoid missed diagnoses.18 PREVALENCE AND COST TO NHS

Osteoporosis is a major public health problem because of its potentially severe consequences for both the patient and the healthcare system if it leads to fracture.12 Osteoporotic fractures are associated with pain, disability and up to 30% mortality at one year.12 The prevalence of osteoporosis amongst the CD population has been estimated to be 6%, although some studies have indicated that it may be as high as 50%.10 NHS data indicates that the cost of treating osteoporosis in those with CD may lie somewhere between £2.3 million and £21.3 million per year.5 MEASUREMENT OF BMD

BMD should be measured in those at high risk of osteoporosis.15 It can be expressed as the number of standard deviations (SD) above or below either the mean BMD for young adults (T-score) or the mean BMD for age-matched controls (Z-score).12 BMD is usually measured using dual energy x-ray absorptiometry (DEXA), which is relatively simple and non-invasive and demonstrates a good degree of accuracy and precision (measurement error of 5-6%).12

The Primary Care Society for Gastroenterology (PCSG)9 recommends that BMD be measured at the time of diagnosis and then repeated at the menopause for women, at the age of 55 years for men and at any age should a fragility fracture occur. However, the British Society of Gastroenterology (BSG)12 advises that since there is only a small increase in fracture risk and prospective studies have demonstrated a significant improvement in BMD and calcium absorption after introduction of a GFD, DEXA should only be repeated after introduction of a GFD in the subgroups of patients in whom the risk of osteoporotic fracture is high.12 As there is no reliable scoring system to select those most at risk, common sense suggests that patients with features such as being over 70 years of age, having had a prior osteoporotic fracture, or using corticosteroids, together with having a poor response or adherence to a GFD and a low BMI, should be considered for DEXA.12 MECHANISM OF METABOLIC BONE DISEASE IN CD

The exact mechanism for the association between CD and bone health is not known, but evidence from laboratory-based studies and relatively small investigations in humans supports several possibilities.11,19 One possibility is that CD leads to dietary malabsorption and, thus, deficiency of vitamins and minerals, such as calcium and vitamin D, which are important in bone remodelling.19 Also, patients with CD are at risk of having an inadequate intake of calcium and vitamin D.20 Calcium and vitamin D affect bone health in a direct way by modifying bone turnover.21 They also act indirectly by causing changes in hormone secretion and mineral absorption.21 Calcium and vitamin D seem to have the greatest effect on risk of fracture when given in combination.22 Other nutrients are involved in bone formation and include magnesium, phosphorus and fluoride.23 Normal bone metabolism is supported by zinc, iron, boron, copper and manganese.3

several other organ disturbances.24 In CD, a low blood calcium level can result from a poor dietary calcium intake and/or calcium malabsorption and lead to secondary hyperparathyroidism.7 The overall effect of PTH is to raise plasma levels of calcium through osteoclast-mediated bone resorption,25 which can lead to a reduced BMD and its associated problems. With a deficiency in calcium leading to longterm bone problems and approximately 75% of newly diagnosed patients having some degree of bone loss, the National Osteoporosis Foundation in the United States set the recommended intake for calcium in CD at 1000mg/day (and 1,200mg/ day for postmenopausal women and men >55 years), which is higher than the 700-800mg/day recommended for the general population.20 The current guidance from the BSG15 for adults with CD recommends at least 1,000mg of calcium per day. Calcium supplementation may be required in postmenopausal women with CD15 and should be considered in CD patients who are avoiding calcium-rich dairy foods due to symptomatic lactose intolerance.12

THE ROLE OF CALCIUM

Parathyroid hormone (PTH) is considered the most reliable marker of inadequate calcium availability and its overproduction can be directly or indirectly linked to bone loss and www.NHDmag.com November 2016 - Issue 119

CONDITIONS & DISORDERS

THE ROLE OF VITAMIN D

Vitamin D comes in two main forms: • Vitamin D3 (cholecalciferol) from sunlight and animal sources such as eggs and dairy; • Vitamin D2 (ergocalciferol) from plant sources such as soya milk, rice milk, cheese and spreads. After conversion to its active metabolites, vitamin D facilitates calcium absorption from the intestine and is important for a range of other metabolic processes.26 Vitamin D deficiency is most commonly caused by insufficient exposure to the sun, but may also be due to a low dietary intake or gastrointestinal malabsorption, such as that seen in CD. Vitamin D deficiency causes a long-standing low level of calcium in the blood. The resulting hyperparathyroidism leads to bone resorption and its associated problems, as explained above. Current guidelines recommend measurement of vitamin D levels in patients with CD and replacement where indicated.15 The European Food Safety Authority (EFSA) have recently proposed an adequate intake of 15µg/day (600IU) for adults.27 The Scientific Advisory Council on Nutrition (SACN) recommend an RNI for vitamin D of 10µg /day (400IU) for the UK population aged four years and above.28 This is the amount needed by 97.5% of the population to maintain a serum 25(OH)D concentration of ≥25mmol/L when UVB sunshine exposure is minimal.28 Serum 25(OH)D is a measure of vitamin D status and reflects the availability of vitamin D in the body from both dietary and endogenous sources.26 The strong inverse relationship 38

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between serum 25(OH)D and serum PTH has been used for establishing an ideal 25(OH)D lower threshold level.24 In the UK, 25mmol/L of 25-OHD has been used as the lower threshold for vitamin D adequacy, below which there is an increased risk of rickets and osteomalacia.29,30 OTHER MECHANISMS

Further proposed mechanisms for the association between CD and bone health include hormonerelated disorders, which may contribute to bone loss and fractures.11 In addition to this, thyroid disease is slightly more common in those with CD and hyperthyroidism in particular may be associated with an increased risk of osteoporosis.11 Another possibility is that an increase in the levels of inflammatory cytokines seen in patients with CD, including TNF-alpha, IL-1 and IL-6 may be responsible for an increase in bone resorption.7,19 CONCLUSION

CD is a multifaceted and complex autoimmune condition that can have a number of intestinal and extra-intestinal manifestations and is associated with various metabolic bone disorders. Early diagnosis and management of CD can help to improve outcomes for patients and help prevent the long-term complications of the disease, including a reduced BMD and increased risk of fracture. Clinicians should be made aware of the relationship between CD and bone health, as this may help to improve CD diagnosis rates, as well as improving the diagnosis and management of CD-related bone disorders should they be present.

GLUTEN-FREE PRODUCT LIST Company

Contact information

Product description

Almondy

almondy.com/en; 020-7795 8148 info@almondy.se

Cakes

Amsia

amisa.co.uk; 0208 547 2775

Pasta, Bread & Pizza base mix, crisp breads, crackers, rice cakes, breakfast cereals, muffins, condiments & seasonings

Bakels

bakelshomebaking.com; 01869 247 098

Bread mixes & cake mixes

Big Oz

www.bigoz.co.uk; 01932 788 373 info@bigoz.co.uk

Breakfast Cereals, flakes & puffs

The Black Farmer

theblackfarmer.com; 0800 0280 559

Gluten free butcher, sausages, meatballs, burgers

Bounce

bouncefoods.com; 0845 838 2579

Snack bars & bites

Easy Bean

easybean.co.uk; 01963 441 493 hello@easybean.co.uk

One pot meals

Eat Natural

eatnatural.co.uk; 01787 479 123

Snacks & breakfast cereals

Feel Free

feelfreeforglutenfree.co.uk; 08081 290 261 hello@feelfreefoods.co.uk

Breads, mixes & flour, pies, quiches, Christmas, Eastern, Italian, breaded fish, sweets & savouries

Fria

fria.se/en/; 01327 871655 info@goodness.co.uk

Bakery items, inc rolls, muffins pizza bases, baguettes

Garofalo

pastagarofalo.it/uk_en/; 39 081 8011002

Pasta

Genius Gluten Free

geniusglutenfree.com; 0800 019 2736

Bakery, frozen pies, sausage rolls, quiche & pastry

Granovita

granovita.co.uk; 01933 273717 info@granovita.co.uk

Granola, juices, meals & snacks, seeds & grains, oils, condiments, sauces, pâté

Hale and Hearty

halenhearty.co.uk ; 020 328 27602 hello@halenhearty.co.uk

Breakfast & cereals, breads & pastas, sweet snacks, home baking, grocery cupboard & festive foods

Heck sausages

heckfood.co.uk; 01845 567 053 sausages@heckfood.co.uk

Sausages, meat balls & burgers

Heinz Deliciously Gluten Free range

www.heinz.co.uk/en/products/gluten-free 0800 528 5757

Pasta, pasta sauces

Honey Buns

honeybuns.co.uk; 01963 23597

Cakes & cookies, baking mixes

Meridian Foods

meridianfoods.co.uk; 01962 761860 website.info@meridianfoods.co.uk

Sauces, pesto, jams, spreads, salad dressings, nut/seed butters, nut bars, natural sweeteners

Mrs Crimble’s

mrscrimbles.com; 01256 393460 info@mrscrimbles.com

Cakes & biscuits, home bake mixes, sweet & savoury snacks, fusilli pasta in a tomato sauce

Munchy Seeds

munchyseeds.co.uk trade@munchyseeds.co.uk

Seeds, seed mixes, seed bites & seed bars

Nature’s path

naturespath.co.uk; 0800 0723658 contactUK@naturespath.com

Breakfast cereals & snack bars

Nairn’s

nairns-oatcakes.com; 0131 620 7000

Oatcakes, crackers, biscuits, fruit bars, muesli, porridge

Nestle

nestlecereals.co.uk; 0800 0789 0789

Breakfast cereals, flakes & puffs

Newburn Bakehouse newburnbakehouse.com; 0800 243 684 by Warburtons

Bread, rolls, wraps, sandwich thins, baguettes, muffins, crumpets

Orgran

orgranglutenfree.co.uk; 020 8208 2966

Pasta, snacks baking, breakfast, kids snacks, gravy, falafel & pizza mix & breadcrumbs

Provena

provena-gluten-free.co.uk

Baking mixes, flours & breakfast goods

Primrose Kitchen

primroseskitchen.com; 01300 345226 info@primroseskitchen.com

Muesli, nut & seed butters, sprinkles, superfood smoothie boosters, hampers & granola

Rizopia

rizopia.co.uk; 01992 581715

Gluten-free organic pasta

Santa Maria

santamariaworld.com/uk/; 0800 018 0002 feedback@santamariaworld.co.uk

Some gluten-free products within their mexican range

Wellabys

wellabys.co.uk; 30 23410 71195 info@wellabys.gr

Snack treats

www.NHDmag.com November 2016 - Issue 119

GLUTEN-FREE PRODUCT LIST Online retailers (not including supermarkets) Abel & Cole Ltd

abelandcole.co.uk/groceries/freefrom Various - online store inc meals, snacks, sauces, pasta, 08452 62 62 62; organics@abelandcole.co.uk pizza, noodles, sweets

Baked To Taste

bakedtotaste.co.uk; 01404 47904 g-free@tiscali.co.uk

Pasties, pies, sausage rolls, quiches, tarts, cakes, bread, pastry, scones

Better Life Bakery

betterlifebakery.com; 01254 610895

Biscuits, cakes, puddings, pastry, savoury pies & sweet pies

BFree foods

bfreefoods.com; 00353 1 7790500 info@bfreefoods.com

Online bakery - bread, rolls, pitta bread, bagels, wraps & fajita kits

Clives Pies

clivespies.co.uk; 01364 642 279 sally@clivespies.co.uk

Pies, pasties, rolls, cakes, flapjacks, dips & one pot meals

Dean’s

www.deans.co.uk; 01466 792086

Range of shortbread biscuits

Delicatezza

delicatezza.co.uk; 020 7607 5556 contact@delicatezza.co.uk

Italian delicatessen, pasta, risotto, sausages, pesto & sauces

Delicious

Alchemydeliciousalchemy.com; 0114 272 7782

Baking mixes, Bread mixes, Breakfast products, stuffing mix

Doves Farm Foods Ltd

dovesfarm.co.uk; 01488 684880 mail@dovesfarm.co.uk

Various products - online store

Schär

schar.onlineshop.uk.com/Store/3 0800 161 5838; share@schar.co.uk

Various - online store, bread, snacks, biscuits, pizzas, frozen ready meals

Freego

freego.com

Various products - online store

Gluten Free Kitchen

theglutenfreekitchen.co.uk; 01969 622222 info@theglutenfreekitchen.co.uk

Online bakery - sweet & savouries

Gluten Free

Shopgluten-freeshop.co.uk; 0203 488 0002 info@gluten-freeshop.co.uk

Various products - online store

Goodness Direct

goodnessdirect.co.uk; 0871 871 6611 info@GoodnessDirect.co.uk

Various products - online store

Green’s Beers

glutenfreebeers.co.uk; 0161 456 4226 info@glutenfreebeers.co.uk

Beers & ales

Hambleton Breweries

hambletonales.co.uk; 01765 640108 office@hambletonales.co.uk

Gluten & wheat-free ale

Ilumi

ilumiworld.com; 0800 505 3232 shop@ilumiworld.com

Indian, Chinese, Mediterranean dishes, hampers, porridge, pasta, rice noodles, soups

Lovemore Free From

Foodslovemorefoods.com; 01685 813 545 lovemore@welshhills.com

Cakes, biscuits & cookies, tarts & pies, crispbreads & seasonal

Mandy’s Gluten Free

glutenfreefoodproducts.co.uk; 01388 661334 admin@glutenfreefoodproducts.co.uk

Pies, quiches, scones, muffins

Morley’s of Swanland

glutenfreebutcher.co.uk; 01482 634 225 gf@glutenfreebutcher.co.uk.

Sausages, pies, savouries, specialities

Natural Grocery

naturalgrocery.co.uk; 01242 572 323 info@naturalgrocery.co.uk

Various products - online store

Naturally Good Food

naturallygoodfood.co.uk; 02476 541990 orders@naturallygoodfood.co.uk

Various products - online store

Oakhouse Foods

oakhousefoods.co.uk; 0333 370 67000

A large selection of frozen ready meals

RealFoods

realfoods.co.uk; webshop@realfoods.co.uk

Various products - online store

Simply Free

simply-free.co.uk; 01582 840502 enquiries@simply-free.co.uk

Various products - online store

Wellfoods

wellfoods.co.uk; 01226 381 712 janet@wellfoods.co.uk

Loaves, rolls, buns, flour, pizza bases, prescriptions

Prescription/NHS suppliers Bialimenta

drossa.ltd.uk; 020 3393 0859 orders@drossa.co.uk

Pastas & flours

Drossa Limited

drossadirect.co.uk; 020 3393 0859

Various products - online store

www.NHDmag.com November 2016 - Issue 119

GLUTEN-FREE PRODUCT LIST Finax

finaxglutenfritt.se/; 46 42-29 86 05 info@finax.se

Breakfast products, crispbreads, flours & mixes & crackers

General Dietary

generaldietary.com; 0203 044 2933 info@generaldietary.com

Various products - online store - prescriptions

Genius Gluten Free

geniusglutenfree.com; 0800 019 2736

Bakery, frozen pies, quiches, pastry & Livwell products

Glutafin

glutafin.co.uk; 0800 988 2470 glutenfree@glutafin.co.uk

Gluten-free prescription products, including breads, rolls, mixes, pasta, pizza bases, crackers, breakfast cereal & sweet biscuits

Gluten Free Foods Ltd

glutenfree-foods.co.uk; 020 8953 4444 info@glutenfree-foods.co.uk

Various - online store

Juvela

juvela.co.uk ; 0800 783 1992 info@juvela.co.uk

Essential gluten-free foods on prescription, including bread, flour, breakfast cereals, pasta & crackers

Nairn’s

nairns-oatcakes.com; 0131 620 7000

Oatcakes, crackers, biscuits, muesli, porridge

Newburn Bakehouse newburnbakehouse.com; 0800 243 684 by Warburtons

Bread, rolls, wraps, sandwich thins, baguettes, muffins, crumpets

Oakhouse Foods

oakhousefoods.co.uk; 0333 370 67000

A large selection of frozen ready meals

Orgran

orgranglutenfree.co.uk; 020 8208 2966

Pasta, Snacks Baking, Breakfast, Kids snacks, gravy, falafel & pizza mix & breadcrumbs

Proceli

proceli.com/eng; info@proceli.com 0034 93 784 83 82

Pure Gluten Free

pureglutenfree.co.uk; 01706 746713 info@pureglutenfree.co.uk

Rizopia

rizopia.co.uk; 01992 581715

Breads, bagels, crisps, granola, snacks, baking mixes, sweet treats

Tobia Teff

tobiateff.co.uk; 0207 018 1210 info@tobiateff.co.uk

Brown & white teff flour, biscuits & bread

Wellfoods

wellfoods.co.uk; 01226 381 712 janet@wellfoods.co.uk

Loaves, rolls, buns, flour, pizza bases, prescriptions

Wiltshire Farm Foods

wiltshirefarmfoods.co.uk; 0800 077 3100

Ready meals inc breakfasts, desserts & pureed meals, all for home delivery

Breads, rolls, buns, muffins, cookies, croissants, pasta, wafers, breakfast cereals, kids range Flours & baking ingredients including prescription

Resources and information BDA Gastroenterology Special Interest Group (GSG); bda.uk.com; 0121 200 8080; info@bda.uk.com Coeliac UK; www.coeliac.org.uk; 0333 332 2033; dietitian@coeliac.org.uk British Society of Gastroenterology; bsg.org.uk; 020 7935 3150; r.gardner@bsg.org.uk Live Gluten Free; liveglutenfree.co.uk; 01738 23 70 70; info@liveglutenfree.co.uk Gluten Free for RDs; glutenfree.com; customerservice@glutenfree.com Food Intolerance Network; food-intolerance-network.com; officeuk@food-intolerance-network.com CORE - fighting gut and liver disease; corecharity.org.uk; 020 7486 0341; info@corecharity.org.uk Schär Club; www.dsglutenfree.com/en/; 0800 161 5838; info@dsglutenfree.co.uk Dr Schar Institute; drschaer-institute.com; 0800 988 8470; professionals@drschaer.com Glutafin; glutafin.co.uk; 0800 988 2470; glutenfree@glutafin.co.uk Juvela – supporting healthcare professionals; juvela.co.uk; 0800 783 1992; hcp@juvela.co.uk Nutrition Society; nutritionsociety.org; 020 7602 0228; office@nutritionsociety.org.uk Patient UK; patient.co.uk Primary Care Society of Gastroenterology; pcsg.org.uk; 020 3872 490; secretariat@pcsg.org.uk Beyond Celiac (US); www.beyondceliac.org; 1-215-325-1306; info@beyondceliac.org Uni of Chicago Celiac Disease Centre (US); cureceliacdisease.org; 1-773-702-7593 Celiac Disease and GF diet Information (US); celiac.com Celiac Disease Awareness Campaign (US); celiac.nih.gov; 1-800-860-8747; healthinfo@niddk.nih.gov

www.NHDmag.com November 2016 - Issue 119

New When Calories count and so does Tolerance NEW - Nutrini Peptisorb Energy The peptide feed specially designed for children who need more nutrition in a smaller volume.

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PAEDIATRIC

Alison O’ Sullivan HCPC Registered Dietitian, ANutr Associate Nutritionist, Early Start, London Borough of Newham

Throughout her career Alison has worked in a variety of settings, including hospitals, charities and, currently, within the community. Her expertise lies in the area of health promotion, with a particular interest in paediatric nutrition.

INTRODUCING SOLID FOODS: SUPPORTING PARENTS THROUGH EVIDENCE-BASED COMMUNITY SESSIONS The Early Start Wellbeing and Nutrition Team supports families in the London Borough of Newham through their work with children’s centres and nurseries. With approximately 25% of reception aged children overweight or obese and 23% of three-year-olds experiencing dental decay in Newham, the team plays a key role in health promotion within the borough.1,2 Understanding the association between unhealthy lifestyle choices and increased risk of related chronic disease, such as obesity, cardiovascular disease, high blood pressure and diabetes, 3,4 the service aims to promote healthy behaviours and lifestyles from an early age.

EARLY LIFE AND PARENTAL INFLUENCE

Overweight and obese children are more likely to become obese adults.5 Currently, one in five children at reception age in England are overweight or obese,1 which highlights the importance of promoting a healthy weight and lifestyle from birth, long before a child reaches reception. A child’s experience in early life can often determine future lifestyle factors, such as food preference and physical activity.3,4 Parents play a key role in providing these experiences during infancy and early childhood. The appropriate introduction of solid foods is a key aspect of this, as it is the beginning of a child’s relationship with food. Parents make the important decision of when to start and what to offer their child and, at times, these practices may not reflect national guidance.

MY ROLE IN THE COMMUNITY

As a Registered Dietitian working within the community, I have experience of supporting a wide range of pro-fessionals through delivery of training to early years’ staff, teachers, health visitors, school nurses and other healthcare professionals. Through delivery of a health award scheme to children centres and nurseries, I have supported staff to develop and implement best nutrition practice within these early years’ settings. I have provided evidence-based nutrition support to families through a variety of practical cooking classes and group education sessions, in particular focusing on the introduction of solid foods. Table 1: Age at which parents introduced solid foods to their infant6 Introduced solids by 6 weeks

Introduced solids by 3 months

Introduced solids by 4 months

Introduced solids by 5 months

Mothers under 20yrs of age

15%

57%

85%

All

30%

75%

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PAEDIATRIC The most recent Infant Feeding Survey (IFS) in 20106 revealed that approximately 75% of parents had introduced solid foods before the Department of Health’s recommended age of around six months (Table 1). Offering fresh whole family foods at this influential time is recognised as a key priority during the introduction of solid foods. The IFS highlighted, however, that approximately 38% of Stage 2 infants and 44% of Stage 3 infants had been offered readymade baby food, the day before the survey was completed. Similarly, the survey reported that 46% of parents had not introduced their baby to a cup at six months, as recommended by the Department of Health.7 Data collected at Introducing Solid foods groups delivered by the team across children’s centres in Newham, from 2013 to 2015 (Figures 1 and 2) continued to identify an ongoing need for parental education around the introduction of solid foods. It is clear that parents play a significant role in shaping a child’s diet and lifestyle behaviours, but where can they go for reliable knowledge, tips and advice? INFORMATION AND GUIDANCE AVAILABLE TO FAMILIES

Parents are encouraged to speak to their Health Visitor, GP or other appropriate healthcare professionals about introducing solid foods. In today’s society, however, there is a strong

Resources provided to parents when attending Introducing Solid Foods Stage 1 and 2/3 groups.

culture of ‘going online’ to find answers to any queries or questions. While an increasing amount of information is available online, parents can often receive mixed messages about when to start introducing solid foods and which foods to offer. It can be difficult to navigate through forums and online message boards and distinguish evidence-based information from opinion. Advice from family members and other parents can also influence a parent’s choice or decision around weaning and, at times, create more confusion. For these reasons, group education sessions delivered by trained professionals are a useful forum to support families to introduce solid foods in a safe and enjoyable way, in line with Department of Health guidance.7 The groups serve as a way of bringing evidence-based

Table 2: Introducing solid foods, Stage 1 and Stage 2/3 Introducing solid foods Stage 1

Introducing solid foods Stage 2/3

• • • • • • • • • • • • • • • •

• • • • • • • • • • • •

Benefits of breastfeeding Tips if a parent is formula feeding Age to introduce solid foods Risks of early weaning Signs baby is ready for solid food First foods to offer Importance of iron rich foods Information on appropriate textures Dealing with food refusal Useful equipment Food safety Shop bought v homemade baby food Food allergies Drinks, cups and oral health Vitamin drops and the Healthy Start Scheme Many other helpful tips www.NHDmag.com November 2016 - Issue 119

Benefits of breastfeeding Tips if a parent is formula feeding Moving on to lumps and thicker foods Finger foods Achieving a balanced diet Importance of iron rich foods Moving onto family foods Shop bought v homemade baby food Food allergies Drinks, cup and oral health Vitamin drops and the Healthy Start Scheme Many other helpful tips

Figure 1: Pre- and post-evaluations completed by parents attending an Introducing Solid Foods Stage 1 group between 2013 and 2015

At what age should your baby start moving onto ‘family foods’?

At what age should your baby be taking all drinks from a cup?

Which food would be an ideal food for introducing lumps to your baby?

What is the recommended age to begin offering foods with lumps to a baby who started solid foods at 6 months?

% of questions answered correctly

Figure 2: Pre and post-evaluations completed by parents attending an Introducing Solid Foods Stage 2/3 group between 2013 and 2015

Evaluation Questions

When do you need to start brushing baby’s teeth? If you give fruit juice to your baby, you should make sure it is diluted (1part juice and 10 parts water) and offered in a _____at _____times. Iron is important for babies. Which food provides the most iron

Which food would be an ideal first weaning food for your baby? What is the recommended age to start introducing solid food to your baby?

% of questions answered correctly

www.NHDmag.com November 2016 - Issue 119

PAEDIATRIC

Overall, we found parent’s knowledge increased by 29% and 34%, following attendance at Introducing Solid Food Stage 1 and 2/3 groups, respectively. advice to families’ attention, while dispelling myths and common misconceptions. INTRODUCING SOLID FOOD GROUPS

Educational groups delivered by the Newham team during 2013-2015 included Introducing Solid Foods Stage 1 (for infants aged four to six months) and Introducing Solid Foods Stage 2/3 (for infants aged seven to 12 months). Parents received age-appropriate, evidence-based advice and support through interactive group sessions. Topics covered are included in Table 2. To support parents to put guidance into practice at home, during these group sessions parents were provided with recipe booklets, an open topped cup, a toothbrush pack and further supportive information (see picture p44). The sessions were an ideal opportunity for parents and carers to raise any other concerns around feeding or development, allowing the facilitator to signpost families onto appropriate healthcare professionals. As part of the sessions, parents were en-couraged to complete a pre- and post-evaluation to demonstrate their change in knowledge following attendance. Questions asked were focused on behaviours and knowledge that would support their child’s long-term health and development. RESULTS

Results accumulated over a two-year period from 2013-2015 found that sessions increased families’ knowledge of a number of key principles around introducing solid foods and promoting oral health (Figures 1 and 2).

CONCLUSION

Results collected between 2013 and 2015 highlight the positive impact that culturally tailored, interactive nutritional education sessions within the community can have on a parent’s knowledge and confidence in introducing solid foods to their child. Overall, we found parent’s knowledge increased by 29% and 34%, following attendance at Introducing Solid Food Stage 1 and 2/3 groups, respectively. The need for ongoing support for parents and carers through interactive workshops and sessions is clear. Despite widely available information on weaning and healthy eating online, our experience has found that parents often remain unsure of many key health messages, or where to find this information. These sessions can also act as a useful way of bringing online evidence-based sources of information to parent’s attention, with the hope that they will continue to refer to these reliable sources as their child grows and develops. The Early Start Wellbeing and Nutrition team currently delivers training to staff within early years’ settings, supporting them to impart clear health messages around nutrition for the under 5s, with a focus on the introduction of solid foods. By training front line staff who have contact with parents on a daily basis, we hope that evidence-based advice will be widely shared, both among families and throughout the community, ensuring ongoing support around the introduction of solid foods.

References 1 National Child Measurement Programme - England, 2014-15 2 Dental public health epidemiology programme, 2013. Oral health survey of three-year-old children. 3 Department of Health (2011). Start Active, Stay Active: A report on physical activity for health from the four home countries 4 Foresight (2007). Tackling Obesities: Future Choices - Project report 5 National Obesity Observatory (2016). Health Risks. www.noo.org.uk/NOO_about_obesity/child_obesity/Health_risks 6 Infant Feeding Survey UK (2010) 7 Department of Health (2011). Introducing Solid Foods

www.NHDmag.com November 2016 - Issue 119

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OBESITY MANAGEMENT

MEAL REPLACEMENTS IN OBESITY MANAGEMENT Maria Dow Freelance Dietitian

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

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

The aim of this article is to examine the evidence behind low calorie dietary approaches to the management of obesity, such as Meal Replacement and Total Diet Replacement programmes for weight loss and weight loss maintenance. The prevalence of obesity has increased steadily over the past 40 years. The rise in the number of obese persons in the UK who have a BMI >30kg/m2 and <40kg/ m2 appears to have slowed down over the past 15 years. There is, however, a continuing rise in the prevalence of persons with a BMI ≥40kg/m2.1 Many programmes of weight management realistically aim for losses of 5-10% which result in clinically significant health benefits.2,3 It is recommended that those with a BMI ≥35kg/m2 with an obesityrelated disease, or BMI>40 kg/m2, should aim to lose at least 15kg or 15% body weight for both improved clinical outcomes and quality of life.2 Weight reduction requires adherence to an energy deficit diet over time. The larger the energy deficit the greater the weight loss. For those persons who have more weight to lose, resorting to more intense programmes of weight management can be tempting. The European Commission Directive 1996 set down the compositional and labelling requirements of foods intended for use in energy restricted diets for weight reduction (Table 1). There is a new regulation on Food for Specific Groups to cover foods for weight reduction from

July 2016.4 Products intended for use in weight management are categorised into Very Low Calorie Diets (VLCD) and Low Calorie Diets (LCD) which can be offered in the form of Meal Replacement (MR) or Total Diet Replacement (TDR) products. VERY LOW CALORIE DIETS (VLCD)

VLCDs contain less than 800kcal per day. Earlier versions of these diets were associated with a number of fatalities due to the low biological value of the protein used. The quality of protein now used has improved significantly. However, it is recommended that VLCDs should not be freely available to the general public for weight reduction.4 Commercially prepared products providing less than 800kcal per day should only be available for the medically supervised treatment of severe obesity.4 Research suggests that adherence to VLCDs is a problem with little difference in 12-month weight change outcomes between VLCDs and LCDs.5 LOW CALORIE DIETS (LCD)

These contain between 800 and 1,200kcal. It is recognised that low calorie diets within these energy restrictions are likely to be nutritionally deficient.3 Commercially prepared nutritionally

Table 1: EU Regulation on food for specific groups and foods for weight reduction 20164 • • •

Sets general compositional and labelling rules for Total Diet Replacement products for weight control. Requires the commission to adopt specific compositional and labelling rules for Total Diet Replacement products for weight control. Establishes rules on the use of statements on Meal Replacement products (between 200 and 400kcal); they should be regulated solely under regulation EC 1924/2006 on Nutrition and Health Claims to ensure legal certainty.

www.NHDmag.com November 2016 - Issue 119

Table 2: Compositional standards of products intended for use in weight control diets Energy

TDR: 800-1200kcals daily MR: 275-400kcals per meal

Protein

TDR 50g or 20% energy MR: 17g or no more than 50% energy

Lipids

TDR and MR: content should not exceed 30% of dietary energy

Carbohydrate and sugars

The remaining % energy to come from carbohydrates

Fibre

TDR: 10-30g daily MR: if product less than 10g fibre, it should be clearly labelled and fibre encouraged from other sources

Vitamins and minerals

TDR: Meet UK RDAs MR: Meet at least 30% of UK RDA per meal

complete products are very attractive options for meals and there is a wide range available to consumers, from full formula shakes and soups, with MR and TDR products designed to replace only one or two meals daily. The European commission has set a minimum supply of protein, vitamins and minerals that must be specified to ensure that energy is the only nutrient that is deficient (Table 2). TOTAL DIET REPLACEMENT PRODUCTS (TDR)

The regulation on food for specific groups states that TDR products are presented as a replacement for the whole of the daily diet.4 There is increasing evidence for the use of nutritionally complete low calorie formula diets used as a TDR to achieve and maintain at least 15kg weight loss at 12 months.6,7 Patients and clinicians need to consider the pros and cons of a TDR programme to ascertain suitability and commitment. TDR programmes allow patients to attain larger energy deficits for longer, therefore, allowing the weight loss expectations of both patient and clinician to be achieved for both clinical and quality-of-life outcomes. Initial rapid weight losses that can be achieved on a low calorie TDR programme have been shown to improve patient retention and long-term results.8 The TDR programme is nutritionally complete, apart from energy, and allows patients to have a break from food which may allow them to focus on other aspects of their lives and behaviours that initially resulted in weight gain. Many patients, however, may struggle with adherence to a low calorie TDR due to the social challenges they may

face while on the programme. This needs to be discussed with patients to ensure they understand the impact that being on a TDR programme may have on families and friends and socially. Products are not available in the healthcare setting and the cost of purchasing these products must be discussed. For many, this cost is offset by savings made by not buying food. Lean et al conducted a feasibility study based in primary care, involving 91 patients with a mean BMI of 48kg/m2. A TDR programme containing 810kcals over 12 weeks was recommended, followed by a stepped programme of food reintroduction and proactive weight loss maintenance. The mean weight change at 12 months was -12.4kg and 44% of completers went on the lose â&#x2030;Ľ15kg body weight at 12 months.7 MEAL REPLACEMENT PRODUCTS (MR)

MRs are specifically formulated foods for use on an energy restricted diet for weight reduction which, when used as instructed by the manufacturer, replace part of the daily diet.4 Products intended to replace only one or two meals must be clearly labelled. It is envisaged that many of these products are commercially available without support and manufacturers are encouraged to indicate to consumers how other meals might be balanced.4 This enables people to attain an adequate intake while maintaining overall energy intake between 800 and 1,200kcals.These products should provide energy in the range of 275kcals to 400kcals per meal (Table 2) and aim to provide between 800 and 1,200cal daily www.NHDmag.com November 2016 - Issue 119

WEIGHT MANAGEMENT MR programmes allow people to consistently achieve a nutrient complete low calorie diet with less meal planning and preparation required. Focus can be spent on just one meal. In contrast to the TDR, MR programmes also allow for family meals with less impact on social occasions. This, however, means the weight losses will be lower, as the daily energy deficit will also be lower. The cost implications must be considered, especially if meals are still being prepared for other members of the family. The use of MRs appears to improve adherence to low calorie dietary plans. Systematic reviews of RCTs indicate that energy deficit diets which incorporate MRs achieve a greater weight loss in overweight and obese adults compared with general dietary advice of similar energy content. In one review, the MR group lost 7-8% body weight compared to 3-7% weight loss in the conventional reduced calorie group. Further analysis of completers showed greater weight loss in the MR group with an extra 2.54kg and 2.63kg loss at three months and one year as compared to the conventional dietary group.9 DISCUSSION

There is a balance to be struck between the risks of someone being overweight or obese and the risks of the weight management treatment, together with the long-term efficacy of the treatment. If a person has a BMI <35kg/m2 with no obesity related comorbidity, clinically significant 5-10% weight losses can be achieved using conventional dietary approaches. MRs have been shown to be a welcome addition to these plans. For those with a BMI ≥35kg/m2, weight losses of at least 15kg are recommended. Only 1.7% of patients with a BMI >30 kg/m2 lost ≥15kg when supported in a successful weight management programme aimed at losing 5-10% weight in the primary care setting.7 Low calorie TDR programmes are the most effective non-surgical weight management solution for these patients.7 The Counterweight plus programme has shown that low calorie liquid diets using TDR with an effective 12-month weight maintenance programme is acceptable to clinicians and morbidly obese patients within routine primary care.7 TDR programmes are gradually being introduced into the NHS as part of the Tier 3 weight 50

www.NHDmag.com November 2016 - Issue 119

management services offered to patients. They are not, however, routinely available. Dietitians are ideally placed to offer these options within their weight management pathways for those patients with higher BMIs. The calorie deficit created by MR and TDR programmes is just one element of long-term success in weight management. Health professionals can ensure that these weight management programmes can be delivered in a safe, structured and efficacious manner. They should incorporate behaviour change strategies known to promote long-term success with weight management, including social support, selfmonitoring, stimulus control, goal setting, slowing rate of eating, problem solving, CBT cognitive restructuring and relapse prevention. WEIGHT LOSS MAINTENANCE

Popular belief is that most people will fail to maintain a lower weight and will experience a weight regain. A structured programme of food reintroduction and weight loss maintenance is key to long-term success. A meta-analysis of studies involving 20 papers and 3,017 patients was undertaken to examine the effectiveness of different approaches in weight loss maintenance after a period of weight loss using a VLCD or LCD. The mean weight change was -12.3kg. Anti-obesity drugs, meal replacements and high protein diets were associated with improved weight loss maintenance outcomes.10 This concords with research by Richelson et al indicating that significant numbers of patients who have been guided through LCDs can maintain ≥15kg weight loss 18-36 months after the initial weight loss phase using structured food reintroduction programmes and antiobesity medications.6 CONCLUSION

Meal Replacements and TDR programmes can be recommended in weight management guidelines for patients with BMI ≥35kg/m2. They enable patients with higher BMIs to achieve and maintain clinically significant and often life-changing weight losses. When used appropriately with support in the right conditions and with a carefully planned programme of food reintroduction and weight loss maintenance, these can be a tool for many patients and dietitians.

FOOD & DRINK

FOOD & NUTRITION ECONOMICS Review by Ursula Arens Writer; Nutrition & Dietetics Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years.

AUTHORS: GEORGE C DAVIS & ELENA L SERRANO PUBLISHER: OXFORD UNIVERSITY PRESS, 2016 ISBN: 978-0199379118 PRICE: Paperback £32.99

This is a book for nutritionists who want to understand the principles and practices of economics. And perhaps also a book for economists who want to relate their skills to a better understanding of nutrition. Both authors lecture at Virginia Tech; he’s an economics Professor and she’s a nutrition Associate Professor. Both rightfully claim expertise in the intersection between nutrition science and economic assessments – perfect fruitful coupling. And both now share their cool analysis of nutrition debate in the language of economics. And never has there been a more useful book for dietitians keen to take part in the many current discussions of national food policy. Economics is the study of choices. We all do this every day as individuals and as groups. Every food purchase we make is an economic vote for one product over another, and supermarket shelves are a near-perfect mirror reflection of whatwe-buy. Many theories of neoclassical economics are simple and logical, but to engage in discussion relating concepts to diet and nutrition, you will need to know the terminology and recognise the main theories. These very useful tools are perfectly developed and tailored just for the dietitian reader. So banish discussions of nutrient content and food enjoyment; consider rather the health and hedonic utility of food choices and the degree to which these may be linear or elastic. Less useful for expert dietitians, are the two chapters of introduction on food, nutrients and health. You should

already know all of this, albeit that the text relates to US data and information systems. But a good review nonetheless, and very useful for non-dietitian readers. Most useful are chapters three to 10. These carefully lead dietitian readers through the logical concepts of classic economics and the less-neat but very current and exciting concepts of behavioural economics. The authors use entirely food choice examples, and make every attempt to keep maths and charts as simple as possible. Within the discussions of how much pizza and how much beer to consume, the authors develop the themes of opportunity costs, isocost and isonutrient lines, and measures of value. Cost per unit weight or serving or food energy are some of the different ways to judge value. But for foods, increasingly the time for purchase and preparation of meals is the driver of decision, and the boom in away-fromhome food purchases perfectly mirror females-in-employment data. The time to select, and skills to prepare, rather than food cost may be the main predictors of consumer food decisions. Then there is discussion of ‘intemporal choice problems’. If ever there was an economic theme directly relevant to dietetic practice, this is it! Food choice is about the balance of health and hedonic qualities of the food, www.NHDmag.com November 2016 - Issue 119

FOOD & DRINK but also about the balance of strength of data with strength of future prediction. If this is sounding Greek (no offence meant to that wonderful Mediterranean country), then thank Davis and Serrano for translating all these concepts to diet choices. It boils down to the certain pleasures of chips now, versus the perhaps far future health from the choice of some cucumber instead. The many counter-intuitive insights developed by Nobel Prize winner Professor Daniel Kahneman are discussed (slow thinking and fast thinking), and again the authors relate all issues to dietetics. So issues of present consumption bias and future discounting relate very directly to obesity treatments. Chapter nine is a goldmine of data describing behavioural economics concepts to diet choice: the terms ‘default effects’ and ‘framing’ should be daily terminology used by every dietitian. Also really interesting are chapters 11 to 13. These set out the economics of food production and supply. Again, all data supplied are US, but concepts apply as well to the UK. So why do farmers only get 3% of consumer spend on food-away from home, but 18% of foods-inhome? Does government funding to support farmers really result in subsidising public obesity? Marketing of foods is really about the costs of space and time and form, and when dietitians understand the costs of these different sectors, they will be able to more effectively target their communications for improved food supplies. I found the economic decisions of the hypothetical potato farmer ‘Paul’ particularly interesting: again irrational decisions when viewed from afar, are perfectly clear and logical when set out economically. The authors conclude the obvious to economists but perhaps not always to consumer advocates: it is not what consumers say they want or like, but what consumers pay for, that signal changes to market delivery.

The final three chapters are about the food prices and quantities in competitive markets. Supply side and demand side elasticity are discussed (the famous blades of scissors analogy by economist Alfred Marshall). Best of all, the authors discuss in detail many aspects of the current hot topic of taxing of sugar sweetened beverages (SSB) – if you really want to sound smart on this debate, make sure you mention the weak assessment of supply side elasticity in campaign predictions of SSB tax, described in the award-winning article by Dharmasena, Davis and Capps (2014). Final sections of the book are a description of Cost Benefit Analysis and Cost Effectiveness – there is a difference, and both are increasingly demanded to support funding for nutrition education programs and dietetic staffing. There are no easy answers given on how to get that funding, and the authors share some sympathy for the weakness of many nutrition project assessments in relation to standardised effect measures. This needs to be addressed – over to you (young dietetic researchers with an interest in economics). There are many formulae and charts; the authors insist that they are at the level of elementary math, in which case my skills are below this modest hurdle. But they are optional features with which to engage. The magical treasures of this book are the guided talking-through of economic terms and concepts selected entirely to delight an audience of dietitians. On reading this book you will not only know a dietetic issue; you will also be able to take a side-step, and look at the same subject in a different way and with a different vocabulary. It will not make you an economist, but you will be able to better talk with economists, and they will think more of you. There are not many books that offer such an excellent return for the investment of a few hours of your time and attention. Highly recommended for dietitian readers.

We have two copies of Food & Nutrition Economics by George C Davis & Elena L Serrano to give away in a free prize draw. For your chance to win, please email us at info@networkhealthgroup.co.uk. Closing date for entries is Friday 9th December 2016. 52

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ONLINE RESOURCES

WEB WATCH Useful information, research and updates. Visit www.NHDmag.com for full listings. NICE GUIDELINE/STANDARDS UPDATES NICE QUALITY STANDARD [QS131] INTRAVENOUS FLUID THERAPY IN CHILDREN AND YOUNG PEOPLE IN HOSPITAL Published September 2016 This quality standard covers the management of intravenous (IV) fluids in term neonates (babies born at term or born prematurely with a corrected age of term or more), children and young people under 16 years. It covers IV fluids used for a range of conditions and in different hospital settings. It does not cover term neonates, children and young people with condition-specific IV fluid needs, because they are under the care of specialists due to their specific needs. The following areas are covered in detail - Measuring plasma electrolyte concentration and blood glucose, Assessment of fluid balance, Fluid type for intravenous (IV) fluid resuscitation, Fluid type for routine maintenance and Intravenous (IV) fluids lead (a dedicated healthcare professional responsible for the training, clinical governance, audit and review of IV fluid prescribing, also patient outcomes. The quality standard is expected to contribute to improvements in the following outcomes: • Patient safety incidents resulting from errors in IV fluid therapy • Length of hospital stay • Children’s and young peoples’ experience of inpatient services • Mortality resulting from errors in IV fluid therapy.

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Full details can be found at www.nice.org.uk/ guidance/qs131 NICE QUALITY STANDARD [QS134] COELIAC DISEASE Published October 2016 This quality standard covers the recognition, assessment and management of coeliac disease in children, young people and adults. Food labelling is not covered by the document. The overall aims of this QS is to achieve improvements in the following outcomes: • diagnosis of coeliac disease • growth in children and young people • health-related quality of life • incidence of osteoporosis • incidence of intestinal lymphoma • incidence of vitamin D deficiency • incidence of iron deficiency This QA has been incorporated into the NICE pathway on coeliac disease - http://pathways. nice.org.uk/pathways/coeliac-disease which covers the diagnosis and management of the condition. This most recent QS defines the best clinical practice for coeliac disease. The following areas are discussed in detail Serological testing for coeliac disease, Referral to a specialist, Endoscopic intestinal biopsy, Advice about a gluten-free diet and Annual review. Full information is available at www.nice. org.uk/guidance/qs134

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ONLINE RESOURCES DEPARTMENT OF HEALTH GUIDANCE NOTES ON THE NOTIFICATION OF MARKETING OF FOODS FOR PARTICULAR NUTRITIONAL USES, MEDICAL FOODS AND INFANT FORMULA Updated 3 October 2016 Available at www.gov.uk/government/ publications/infant-formula-and-foods-forparticular-nutritional-uses-parnuts-notificationrequirements. This document provides guidance and notification forms for introducing medical foods and infant formula to the UK. It is aimed at ‘all companies who intend to market for the first time in the UK foods for particular nutritional uses, medical foods and infant formula, and those local authorities who are responsible for enforcing the legislation in this area.’ It sets out to ‘provide non-statutory guidance on the notification rules, which apply to foods for particular nutritional uses, medical foods and infant formula.’Covered in the document are:

• Foods for Particular Nutritional Uses (PNU Foods), e.g. low protein foods and prescribed gluten-free foods • Medical foods, e.g. tube feeds or oral nutritional supplements • Infant Formulae, e.g. any infant formula to be used in the UK. The definition of infant formula - ‘foodstuffs intended for particular nutritional use by infants during the first months of life and satisfying by themselves the nutritional requirements of such infants until the introduction of appropriate complementary feeding.’ Notification of follow-on formulas is not required. Overall, this document has remained the same; the main amendment is the contact details for Nutrition Legislation Team in England and the availability of updated infant formula and special medical foods forms.

ROYAL COLLEGE OF PHYSICIANS NATIONAL CLINICAL GUIDELINE FOR STROKE (5TH EDITION) Published October 2016 This has been prepared by the Royal College of Physicians Intercollegiate Stroke Working Party, chaired by Professor Tony Rudd. The working party also supervises the National Audit Programme for Stroke. The National Institute for Health and Care Excellence (NICE) have recognised this 2016 edition of the guideline. This guideline provides a complete overview of stroke care, taking into consideration the whole of the stroke pathway from acute care through to longer-term rehabilitation, including secondary prevention. Healthy diet and lifestyle recommendations are discussed as part of the secondary preventative measures for stroke, with nutrition and hydration being part of the rehabilitation guidance in the management pathway. Dysphagia and dietary modification are also included.

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The full guideline can be viewed and downloaded at www.strokeaudit.org/Guideline/ Full-Guideline.aspx CONSULTATION RESPONSE: SOFT DRINKS INDUSTRY LEVY Published 13 October 2016 The government recently announced that it would introduce a new Soft Drinks Industry Levy from April 2018. The Obesity Health Alliance, a coalition of over 30 charities, medical royal colleges and campaign groups, including the RCP, have put together a response to express its views on the design and implementation of the proposed levy. The OHA believes that a soft drinks levy is a positive measure in tackling the worrying levels of overweight and obesity in the UK. It supports the Government’s proposals to introduce a soft drinks industry levy. Read the full response at www. rcplondon.ac.uk/guidelines-policy/consultationresponse-soft-drinks-industry-levy

DATES FOR YOUR DIARY UNIVERSITY OF NOTTINGHAM SCHOOL OF BIOSCIENCES

Modules for Dietitians and other Healthcare Professionals • Diabetes I (D24D01) 22nd & 23rd November 2016 & 26th January 2017

Next steps for tackling obesity: prevention, sugar consumption and policy priorities Scotland Policy Conferences Keynote Seminar 16th November - Central Edinburgh www.scotlandpolicyconferences.co.uk/forums/ book_event.php?eid=1259&type=parl-offs Diabetes Professional Care 2016 Leads the Way in Innovation 16th November - Olympia, London www.diabetesprofessionalcare.com

• Diabetes 2 (D24D02) 12th & 13th January & 15th, 16th, & 17th March 2017

• Understanding Behaviour Change (D24UCB) 8th, 9th & 10th February & 23rd March 2017 For further details, please email Katherine. lawson@nottingham.ac.uk, or check out the University website at www.nottingham.ac.uk/ biosciences and click on ‘Study with us’ and then ‘short courses’ which will take you to ‘for practising dietitians’.

Multidisciplinary Stroke Educational Programme 23rd & 30th November - Conference Centre, Nottingham University Hospital www.ncore.org.uk, email: dhft.ncore@nhs.net Gastrostomy Study day 24th November - Holiday Inn, Regents Park, London www.vygon.co.uk/training/studydays Research methods and critical appraisal courses 26th November - Royal Society of Medicine, London www.rsm.ac.uk/events/rpg10 Contact: Lucy Church, rsmprofessionals@rsm.ac.uk

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

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• Premier & Universal placement listings • NHD website, NH-eNews and NHD Magazine placements To place an ad or discuss your requirements please call

0845 450 2125 (local rate) www.NHDmag.com November 2016 - Issue 119

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.

This month’s Final Helping is likely to be even more ‘around the houses’ than usual. Tomorrow (as I write this), I am going to a funeral in Bury, near Manchester, of a dietetic colleague and friend of many years. No doubt I shall see some familiar faces there, most from my own era. It will focus the mind. On the way, I’m dropping off my Dansette Conquest Record player, a 17th birthday present from my parents, to see if this wellpreserved piece of my life needs a new stylus and a service after 50 plus years of first regular and, more recently, occasional use playing 45s and Beatles LPs! Now having more time to read newspapers and books as opposed to professional journals, my attention was drawn this week to an article by Liz Jones in The Mail on Sunday. Some of you may have heard of Liz who is a writer and journalist and has had an eating disorder for many years. She has openly discussed this in numerous articles. This particular article begins: “Appalling I know, but sometimes I’m glad I have an eating disorder.” She states that she is going abroad for a fortnight, mainly to avoid seeing herself on TV. “I’ve just made an embarrassing, unedifying programme entitled, Me and My Eating Disorder. In it, I talk frankly about the fact that I’ve starved myself since the age of 11 and continue to starve myself at the grand old age of 58.” In her time, Liz has generated much adverse comment about her views and opinions and has not been shy about exposing her personal life and food habits. “I realise the world inhabited by ‘normal people’, i.e. those who eat more than my eight calories a day, is closed to me.”

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I’ve just heard that girls as young as 11 can now be electronically altered in their school portraits to improve how they look. My own thoughts go back to my time as a student dietitian on a third-year placement in a Glasgow hospital. At the start of my second week on a ward round with a Senior Dietitian, I saw a 17-yearold girl on a drip. She was surrounded by photographs of how she was before. Some were pictures of her on her own, others were with family and friends. She was happy, beautiful, vivacious, loving and talented. I was told that she had ‘anorexia’. It was my first experience of an eating disorder. I saw her twice more that week. The following week I was told that she had died. It made a lifelong impression on me as a young student. Liz Jones recognises that this illness is dangerous and life-shortening, but she states, “The overriding feeling I wake up with every day is one of superiority.” I’ve just heard that girls as young as 11 can now be electronically altered in their school portraits to improve how they look. Some lifelong and life-threatening beliefs are made at an early age when you can be readily manipulated. On my way back from the funeral tomorrow, I hope to pick up my Dansette. “If music be the food of love… all you need is love!” R.I.P Jennifer Coutts. Colleague and friend.