Network Health Digest - March 2017 by NH Publishing Ltd

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

NHDmag.com March 2017: Issue 122

Hydration and malnutrition in the elderly FALTERING GROWTH COELIAC DISEASE IMD WATCH EFFECTIVE MDT WORK

Malabsorption Pages 23 to 29

7 Red Flag Indicators for when to use an AAF 1. INFANTS SYMPTOMATIC ON AN eHF1-3 2. SEVERE GI SYMPTOMS1-4 3. FALTERING GROWTH2,3,5 4. MULTIPLE FOOD ALLERGIES1,5 5. SEVERE ECZEMA1-3,5 6. INFANTS SYMPTOMATIC ON BREAST MILK1-3,5 7. ANAPHYLAXIS3,4

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Neocate: The UK’s No. 1 Amino Acid-Based Formula References: 1. Koletzko S, Niggemann B, Arato A, et al. J Pediatr Gastroenterol Nutr 2012; 55(2):221-229. 2. Venter C, Brown T, Shah N, et al. Clinical and Translational Allergy 2013; 3(1):23. 3. Ludman S, Shah N, Fox A. BMJ 2013; 347-355. 4. Fiocchi A, Brozek J, Schünemann H, et al. WAO J 2010; 3:57-161. 5. Hill DJ, Murch SH, Rafferty K et al. Clin Exp Allergy 2007; 37(6):808-822. 6. De Boissieu D, Matarazzo P, Dupont C. J Pediatr 1997; 131(5):744-747. 7. Vanderhoof JA, Murray MD, Kaufman S et al. J Pediatr 1997; 131 (5):741-744.

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FROM THE EDITOR

WELCOME Emma Coates Editor

Roar! They always say that March comes in like a lion and goes out like a lamb. This month we bring you to this bright and breezy issue of NHD with a refreshing mix of articles to tantalise any nutritional palate. Not a lion in sight, sorry!

Emma has been a registered dietitian for 10 years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the NHS. She has recently moved into industry and currently works as Metabolic Dietitian for Dr Schar UK.

The month of March brings us the global event that is Nutrition and Hydration Week (13th-19th March 2017). It was initially developed from a collaboration between Patient Safety Domain NHS England, Hospital Caterers Association and National Association of Care Catering, with an aim to improve nutrition and hydration across both health and social care. The event is now recognised on a global level with support in Spain, Sweden, Australia and many other countries. Caroline Lecko, Patient Safety Lead, NHS Improvement, explains more about the event and what it means – there’s still time for you to get involved. We also have an article from the BSNA’s Naomi Johnson which highlights the impact and challenges of managing malnutrition and hydration in elderly care homes. Optimal nutrition and hydration are essential at all stages of the lifespan and Kate Roberts RD discusses the consequences and management of Faltering growth in the first of her two paediatric articles for us this month. Kate provides an overview of faltering growth with a worked example of treatment via her case study. In the second of her articles, Kate shares her insights into the management of Paediatric coeliac disease and the gluten-free diet, an essential dietary modification for this patient group. However, the growing trend of free-from diets as a lifestyle choice can at times bring difficulties to those with a genuine medical diagnosis of coeliac disease, or food allergy and intolerance. In Ursula Aren’s Face to Face column this month, she meets Michelle Berriedale-Johnson, Director of Freefrom

Food Awards, Author and consultant on free-from foods, to discuss her career. Whilst the free-from food sector has seen a boom in consumers flocking to take up this diet in the hope of finding wellness, or to lose weight or perhaps treat as self-diagnosed allergy or intolerance, there are other food trends afoot. In our online subscriber supplement NHD Extra, Priya Tew RD takes us on a tropical trip through the nutritional value of coconut foods. Unfortunately, we aren’t talking about Pina Coladas and macaroons here, but the phenomenon of using all things coconut, such as flour, sugar and oil to cook and bake with. The commercial diet sector isn’t the only sector to see big changes in product use, IMD Watch this issue is brought to us by Helen Rose RD focuses on the legislation for products used in the management of inborn errors of metabolism. Our clinical practice features for this issue have been written by Nikki Brierley RD and there’s a contribution from myself too. Nikki returns to NHD to put the spotlight on MDT working, drawing on her experience as a clinical dietitian. She discusses how MDT can be initiated and monitored to bring about the most efficient practice. My contribution focuses on Malabsorption, a broad topic, so, I have devised a general overview for you. Check out Dr Emma Derbyshire’s Food for thought on her acrylamide concerns update. This news hit the headlines a few weeks ago following the FSA’s launch of their ‘Go for gold’ campaign. Baaaa! Little lamb, over and out…! Emma www.NHDmag.com March 2017 - Issue 122

CONTENTS

11 COVER STORY Hydration & malnutrition in the elderly

News

Nutrition and Hydration Week

Latest industry and product updates

41 Face to face with Michelle Berriedale-Johnson

44 SKILLS & LEARNING Effective MDT work

Celebrating this annual event

19 PAEDIATRIC COELIAC DISEASE and the gluten-free diet 23 Malabsorption Causes, stages and treatment

47 NHD Readership Survey A roundup of the results 50 Web watch Online resources

and updates

30 IMD watch The impact of EU legislation

52 Events & courses, dieteticJOBS Dates for your diary and

FALTERING GROWTH Case study

job opportunities

53 The final helping The last word from Neil Donnelly

Copyright 2017. 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

www.NHDmag.com March 2017 - Issue 122

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

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.

ACRYLAMIDE CONCERNS The latest set of data from The Total Diet Study (2014-2015) has been published,1 highlighting that the UK population may be exposed to a range of chemicals in food, including acrylamide. Acrylamide is a chemical that forms when some foods are subjected to high temperatures during cooking and processing. It is found in a wide range of home-cooked and processed foods. The recent study revealed the highest concentrations of acrylamide was found in snacks - particularly fried potatoes and cereal food groups, including breakfast cereals and sweet biscuits, although levels were found in most food groups, making it impossible to avoid complete exposure. Following publication, the Food Standards Agency have launched their ‘Go for Gold' campaign2 to highlight the issue of acrylamide in food and help consumers minimise their exposure when cooking at home; their recommendations include the following: • When frying, baking, toasting, or roasting starchy foods like potatoes, root vegetables or bread, aim for a ‘golden yellow’ colour or lighter. • Follow cooking instructions carefully to ensure that starchy foods aren’t cooked for too long at temperatures which are too high. • Eat a healthy balanced diet that includes the recommended five-a-day fruit and vegetables. • Don’t keep raw potatoes in the fridge if you intend to roast or fry them; this can increase overall acrylamide levels. Put into context, we shouldn’t be over-browning or burning our food in any way. The Food Standards Agency campaign messaging seems to work; however, as my husband said the other day, “Oh dear, it’s a bit more than gold.” References

1 Food Standards Agency (2017). Total diet study of inorganic contaminants, acrylamide and mycotoxins. www.food.gov.uk/science/research/chemical-safety-research/env-cont/fs102081 2 Food Standards Agency (2017). Families urged to ‘Go for Gold’ to reduce acrylamide consumption www.food.gov.uk/news-updates/news/2017/15890/families-urged-to-go-for-gold-to-reduce-acrylamideconsumption

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NEWS CALCIUM REDUCES LYCOPENE BIOAVAILABILITY Lycopene provides the familiar red colour to fruits and vegetables, especially tomatoes, and is one of the major carotenoids in the diet. Previous research has suggested that dietary intake of this powerful antioxidant may be associated with a reduced risk of chronic diseases such as cancer and cardiovascular disease. The bioavailability of lycopene depends upon several factors, such as food processing or co-ingestion of fat. Now, new research published in the British Journal of Nutrition has looked into the effects of dietary calcium. In a small randomised crossover trial, adults ate either: 1) a meal providing 19mg of lycopene from tomato paste, or 2) the same meal plus 500mg of calcium carbonate in supplement form. Blood plasma lycopene levels were measured regularly over seven hours. The research team found that calcium (in the dose tested) reduced the bioavailability of lycopene by 83%. These are important findings, given that carotenoids are inversely associated with chronic disease. Further research is now needed to ascertain the effects of calcium or other minerals upon their bioavailability.

FOLIC ACID FOR MIGRAINE? Migraine is a common neurological disorder, classified by the International Headache Society as migraine with aura (a recognised sensation) and migraine without aura, with incidences occurring much higher in females than males. Elevated levels of the amino acid homocysteine (hyperhomocysteinemia) are being increasingly recognised, not only as a predictor for chronic disease, but also a risk factor for migraine headaches. Previous research has suggested that lowering homocysteine levels via vitamin supplementation, may reduce migraine occurrence. Women diagnosed with migraine with aura were randomly allocated to take a supplement containing 1mg of folic acid, 25mg of vitamin B6 and 25mg of vitamin B12. Compared to a previous study, using 2mg of folic acid, 25mg of vitamin B6 and 400 micrograms of vitamin B12. Unfortunately, there was no significant decrease in migraine frequency or severity at the end of the six-month intervention. Further research is needed to ascertain the effects of various doses of folic acid, vitamin B6 and B12 regarding not only frequency and severity of symptoms, but also the long-term effects on the general well-being of sufferers.

For more information, see: Borel P et al (2017). British Journal of

10.1186/s10194-016-0652-7.

Nutrition, Vol 116, No 12, pg 2091-96.

Epub 2016 Jun 23.

For more information, see: enon S et al (2016). The Journal of Headache and Pain, Vol 17 (1), 60 doi:

PICKY EATING REDUCES IRON AND ZINC INTAKES Picky eating is a common problem during childhood, often causing considerable parental anxiety. Characterised by an unwillingness to eat certain foods and by strong food preferences, concerns are that picky eating may result in lower intakes of energy and nutrients. New research published in the American Journal of Clinical Nutrition, used data from the Avon Longitudinal Study of Parents and Children to measure the nutrient and food group intakes of children who were identified as picky eaters or non-picky eaters and compared the results with UK reference nutrient intakes. Dietary intake was assessed at 3.5 and 7.5 years of age using a three-day food record. Main findings included that: free sugar intake was higher than recommended amongst picky eaters; picky eaters had lower mean carotene, iron and zinc intakes; nutrient differences were explained by lower intakes of meat, fish, vegetables and fruit. These important findings suggest the need for parents to encourage their children to include more nutrient-rich items, especially fruits and vegetables in their diet and less nutrient-poor sugary foods. Relieving parental concerns of inadequate nutrient intakes will aid in dispelling high controlling practices which may create a negative environment around food and healthy eating. For more information, see: Taylor et al (2016). American Journal of Clinical Nutrition, Vol 104, No 6, pg 1647-1656.

www.NHDmag.com March 2017 - Issue 122

PUBLIC HEALTH

ENGAGING, INSPIRING AND CELEBRATING: NUTRITION AND HYDRATION WEEK Caroline Lecko Clinical Improvement Manager, NHS Improvement

Nutrition and Hydration Week 2017 (13th to 19th March) is upon us. Who would have thought that we would be looking to celebrate our sixth year of a campaign that is quite simply all about engaging, inspiring and celebrating everything that is amazing about nutrition and hydration!

Caroline Lecko is one of the Nutrition and Hydration Week co-leads, a partner at Nutrition and Hydration Associates and currently Clinical Improvement Manager at NHS Improvement.

It is worth just reminding ourselves what Nutrition and Hydration Week is about: it’s a global social movement to improve the provision of nutrition and hydration which started back in 2012 as a one-off patient safety week and how it has grown! Now an annual event, celebrated by many countries around the world, Nutrition and Hydration Week continues to go from strength to strength, thanks to the incredible support of dietitians, caterers, nurses, hospitals, care homes, community services, suppliers and manufacturers. More recently, Nutrition and Hydration Week has seen support from schools and several larger employers. We thank you all for the support and involvement. SO, WHAT HAPPENS DURING THE WEEK 13TH TO 19TH MARCH?

Well, to be honest, anything goes . . . The Nutrition and Hydration Week campaign is not about telling you what to do, as we believe that it is your week and that you should be able to use the week to do the things that are important to you. All we ask is that you share your plans and events with us at Nutrition and Hydration Week, so that we can share them in our newsletters, on social media and on our website. Here are some highlights from 2016: Gillibrand Hall Nursing Care Home held a week-long challenge to increase the fruit and vegetable intake of the 8

www.NHDmag.com March 2017 - Issue 122

residents. Their chef Dan offered smoothies and fresh fruit juice and fruit for breakfast and put fruit in scones and puddings. The Home invited their very own dietitian to an event that was also attended by their nutrition and fluid champions, the chef, nurses and care assistants. The senior management team were also invited to join in with the residents’ dining experience and to talk about the food offered and went on to use the feedback to change the menus. They also held a ‘bake off’ which was judged by the residents and the cakes were served as part of a vintage afternoon tea party. To round the week off, a mocktail party was held, which was a great way to increase fluid intake. Our colleagues at the Hungarian Dietetic Association also had a busy week. After a successful World Tea Party in 2015 with 550 residents, they wanted to make their second World Tea Party event a memorable occasion. The World Tea Party was held at the Department of the Dietetics and Nutrition Sciences of the Semmelweis University on 16th March 2016 and was open to 60 final year BSc students and 20 MSc students of the Department of Dietetics and Nutrition Sciences. The event included a welcome speech by Mrs Jolán Kubanyi, President of the Hungarian Dietetic Association and a presentation entitled ‘Importance of hydration’ by Ms Zsuzsanna Szűcs, Chair of the Science Committee of the Hungarian Dietetic Association. At the event, different kinds of

tea (black, green and fruit tea) (courtesy of Unilever Food Solutions) and bottled drinks (still and sparkling mineral water, juice and ice tea) (courtesy of Coca-Cola Hungary) were provided. There was a little message with every single bottle - an attached hydration recommended intake note (by age and gender) based on EFSA advice for water intake. In addition to this special World Tea Party, the Hungarian Dietetic Association used their Facebook page to deal with the importance of hydration and preventing malnutrition: click here for more.... The Nutritional Academy’s Newsletter in March was linked to preventing dehydration and was sent to the dietitians and the media. Closer to home, our colleagues at Heart of England NHS Foundation Trust had the most amazing tea dance to promote Nutrition and Hydration Week, as well as Dementia on 17th March 2016 for some of their elderly patients. A couple of ballroom dancers from Planet Dance School in Solihull and an organist (who already volunteered within their hospital) joined them and all gave their time freely. Patients were invited from the wards and outpatients, along with some residents from a local nursing home, some of whom had dementia. For the tea dance, they decorated the area with bunting, used china cups and saucers, cake stands for the sandwiches and cakes and made up memory books for the tables which consisted of archive photos from the 1920s-70s of Birmingham City Centre, which were extremely popular and created lots of conversation. All tables had names too, such as The Marilyn Monroe Table, The Rock Hudson Table and The Bette Davis Table. Inspiring!

These are just three of the incredible stories we were told about for Nutrition and Hydration Week 2016. Further examples of events held around the world can be found at www.nutritionandhydrationweek.co.uk/ events/nutrition-and-hydration-week-2016/. Nutrition and Hydration Week is about sharing all the positive things that organisations and individuals are currently doing, or that they do as part of the week - we believe that by sharing examples and stories, we can inspire others to become involved in Nutrition and Hydration Week and to look at how they provide nutrition and hydration within their organisation. In a nutshell, we celebrate all the amazing things that individuals and organisations do. IT’S REALLY NOT TOO LATE TO GET INVOLVED

We will be celebrating Nutrition and Hydration Week from the 13th to 19th March 2017 and we would love you to get involved in any way you can during that week. We also believe in creating a legacy so that you can have your Nutrition and Hydration Week when it works for you and your organisation. (I hope I don’t get told off for saying that!) In the world of improvement, we call this ‘spread’ and creating ‘momentum’, so let’s ‘spread’ the word and create ‘momentum’ for the Nutrition and Hydration Week mission to create a global movement that focuses energy, activity and engagement on nutrition and hydration as a fundamental element of maintaining the health and well-being for our global community. Remember, it’s your week and you must use it to make a difference; all we ask is that you let us know what you are planning so that we can share with our global community as part of our vision to engage, inspire and celebrate.

We, at Nutrition and Hydration Week, personally thank you for all your support over the years, but especially we thank you for making a difference to all your patients, residents, service users, students and employees - you are truly amazing! We hope that your support will continue for 2017.

Please do contact us at: info@nutritionandhydrationweek.co.uk - Caroline www.NHDmag.com March 2017 - Issue 122

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References 1. Wright C. CN Focus 2012;4(3):17-19. 2. Sharma M et al. Colorectal Disease 2013;15: 885-891. 3. Data on file. 4. Malnutrition Advisory Group (MAG) 2011.Malnutrition Universal Screening Tool. www.bapen.org.uk/pdfs/must/must_full.pdf. Accessed September 2016. *Of those who were at medium or high risk of malnutrition at baseline, 67% were at low risk of malnutrition on study completion.

All information correct at the time of print. December 2016

COVER STORY

IN ASSOCIATION WITH THE BSNA

z nt om d e .c tu ag r S Dm ou H to .N w n gi w Lo w

Naomi Johnson Scientific and Regulatory Manager at the British Specialist Nutrition Association

ELDERLY CARE HOMES: HYDRATION AND MALNUTRITION

Good nutrition is important all through life, but never more so than in old age, when a healthy diet is a vital part of any strategy to help older people stay active, disease-free and independent.

Aging can NETWORK itself have a large and linking the results to a care plan.6 HEALTH DIGEST

Naomi has adverse impact on nutritional While these results paint a positive a First Class Honours status, exacerbating the decline in picture, malnutrition is a substantial NHDmag.co Thedegree Magazine for Dietitians, Nutritionists and Healthcare Professionals in Nutritional physiological and psychological func- and ever-growing issue. Estimates Science and an November 2016: Issue 119 tions that occur in later life. Fluid suggest that malnutrition affects three MSc in Public Health Nutrition. balance alterations can commonly million people in the UK,7 with 1.3 She has worked occur in the elderly, leading to a risk million of these being over 65 years of in the nutrition industry for of dehydration.1 age. several years. Malnutrition (which can be both Research shows that 35% of those www.bsna.co.uk

a cause and effect of ill health) and inadequate dietary and fluid intake in old age is a significant risk, which can result in numerous ailments, such as decreased muscle mass, reduced cognitive function, delayed wound healing, constipation, dizziness and increased risk of falls, increased hospital admissions and readmissions and increased mortality.2,3,4 Yet, all too often, malnutrition and dehydration are not recognised, let alone considered a serious and very common problem. Insufficient access to water, poor support with eating and drinking and lack of available oral nutritional supplements (ONS) are unacceptable occurrences that can play a role in the development of malnutrition.5 The National Screening Week (NSW) surveys of UK care settings provide a countywide picture on malnutrition prevalence during 2007 to 2011.6 These surveys included analysis of 474 care homes, which showed that 82-92% had policies for nutritional screening and 91-99% for weighing and recording weight on admission; moreover, 91-96% reported

≥70 years of age who have recently moved into a care home (within the last six months) are malnourished or are at risk of malnutrition (a figure which is consistent across the UK, although was found to be more prevalent in older residents and in women [38%] compared to men [30%]). In a 2012 Care Quality Commission (CQC) Dignity and Nutrition Inspection, one in six care homes showed a failure to support patients in consuming sufficient amounts of food and fluid8 and, in 2017, it is concerning to note that some care homes are still not meeting the requirements for nutrition and hydration. Research published in 2015 by the Journal of the Royal Society of Medicine, analysed acute admissions in 21,510 patients aged >65 years old; patients admitted from care homes had a 10-fold higher prevalence of dehydration than ‘own home’ admissions.9 Care home staff should be able to clearly identify signs of malnutrition and dehydration. However, misconceptions still exist even on the definition of ‘malnutrition’; for some elderly patients who present as obese,

EATING DISORDERS

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COMMUNITY

NICE has calculated that the delivery of better nutritional care could be the sixth largest potential cost saving available to the NHS.

malnutrition may also be present. Older people, carers and families must be fully informed, supported and educated on the importance of preventing and managing malnutrition. Anyone working with patients must have a clear understanding of nutritional care and be appropriately trained and competent to understand the causes, consequences and signs of malnutrition. Screening for malnutrition should take place on admission, or where there is a clinical concern, using the Malnutrition Universal Screening Tool (‘MUST’), the use of which is becoming much more prevalent. The NSW surveys showed awareness of the existence of weight scale standards in only 55% of respondents, whilst 73% undertook audits on nutritional screening.6 Greater awareness is also needed of those patients who may require higher levels of support, i.e. in elderly patients where issues such as dysphagia and dementia may be present.

FINANCIAL IMPACT

While the human cost of malnutrition can be great, so too can the financial impact, as costs continue to rise and become increasingly more exacerbated by an ever-aging population. The cost of managing care home residents diagnosed with malnutrition has been shown to be twice that of screening and monitoring the general care home population.10 The health and social expenditure of disease-related malnutrition is estimated to be £19.6 billion per year in England alone.11 NICE has calculated that the delivery of better nutritional care could be the sixth largest potential cost saving available to the NHS.12 The recent report from the British Association for Parenteral and Enteral Nutrition (BAPEN) and the National Institute for Health Research Southampton Biomedical Research Centre (NIHR), states that it costs three times more NOT to treat or manage a malnourished patient compared to one without malnutrition, equating to £5,329 per patient.11 It also found that implementing NICE www.NHDmag.com March 2017 - Issue 122

HELPING YOU TO UNWRAP THEIR POSSIBILITIES You can support your patientsâ&#x20AC;&#x2122; recovery by choosing the Fortisip range of oral nutritional supplements and help get them back to cooking up a storm

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Nutritional Support - integral to the continuum of care

COMMUNITY Clinical Guidance CG32 and Quality Standard QS24 in 85% of patients at medium and high risk of malnutrition would lead to a net saving of £172.2 to £229.2 million, which equates to £324,800 to £432,300 per 100,000 people. WHAT STANDARDS AND GUIDANCE ARE IN PLACE?

Following and implementing recognised guidance provides a suitable strategy to combating malnutrition within care homes. NICE’s QS24 and CG32 and the Managing Adult Malnutrition in the Community Pathway13 help support healthcare providers to follow the recommended approach to the management of disease-related malnutrition, as outlined in NHS England’s Commissioning Excellent Nutrition and Hydration (2015-2018).14,15,16 These standards and guidance recommend that all care services take responsibility for the identification of people at risk of malnutrition and provide nutrition support for everyone who needs it. Nutritional care provision across all care settings must be multidisciplinary, with everyone having a part to play in ensuring that people receive timely nutrition support whatever that may be, from advice on eating well and food fortification, to needing a prescribable nutritional supplement. It is important that care givers are made aware of the tools available to them. However, it seems that awareness of them is often low.

ORAL NUTRITIONAL SUPPLEMENTS IN THE CARE HOME SETTING

Care home teams need to establish key questions, such as: What is the prevalence of malnutrition? Are care plans in place (and, if so, are they actually being followed)? Are those residents who would benefit from ONS both receiving them, and drinking them? Care providers should refer to the Pathway for using ONS in the management of malnutrition to identify and manage individuals at risk of disease-related malnutrition and appropriate ONS use.13 ONS should be prescribed and used when needed and will typically be used in addition to the normal diet, when diet alone is insufficient to meet daily nutritional requirements and offer a clinically and cost effective way to manage malnutrition.17,18,19 When ONS are used for three months or more amongst malnourished patients in care homes and the community, the median cost saving is 5%, as well as improved clinical outcomes, such as improved quality of life, reduced infections, reduced postoperative complications, fewer pressure ulcers, fewer falls and better wound healing.15,19,20,21 Metaanalysis of trials shows that provision of nutritional supplements to malnourished patients reduced wound breakdown by 70% and mortality by 40%.22 THE POTENTIAL IMPACT OF RECENT RESTRICTIONS OF ONS

Despite the benefits associated with ONS in sub-groups of the population, some Clinical Commissioning Groups (CCGs) have introduced

THE MALNUTRITION TASK FORCE HAS DEVISED FIVE BEST PRACTICE PRINCIPLES TO HELP ADDRESS MALNUTRITION:5

1 Raising awareness among residents, relatives and staff to support prevention and early treatment of malnutrition. 2 Working together within the care home and with external members such as relatives, GPs, therapists, and across other care homes. 3 Identifying malnutrition early. Screening and regular assessment must be carried out to establish residents’ nutritional needs. 4 Delivering personalised care, support and treatment. 5 Monitoring and evaluating residents’ weight, improvements and outcomes.

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COMMUNITY restrictions to prescriptions. Since the end of 2015, some GPs in certain geographical areas have not been able to prescribe ONS (sip feeds) for the majority of residents in catered care and nursing homes, although this policy does not include residents fed via a percutaneous endoscopic gastrostomy tube (PEG tube). Such restrictions to ONS arise as commissioners try to work within increasingly stringent budgets. These policies are misguided and although well intentioned, both fly in the face of the existing evidence and fail to consider long-term outcomes. The Managing Adult Malnutrition in the Community Pathway13 clearly indicates that ONS should be used in combination with food as part of the management of malnutrition; this is also referenced in the recently launched NHS England Commissioning Excellent Nutrition and Hydration (2015-18).16 Any restrictions to nutrition and hydration standards will

necessitate much more stringent monitoring and evaluation within care homes in the months and years to come. CONCLUSION

Nutritional initiatives and publication of numerous standards, including NICE guidance, play a crucial role in tackling malnutrition; however, the aforementioned figures highlight that there is a lot more still to be done and sadly guidance and standards are frequently ignored in practice. Education, training and support of care givers is crucial and goes hand-in-hand with raising awareness and ensuring that the necessary resources are available. Improved efforts across the board to prevent malnutrition and treat it earlier can potentially have major effects in reducing its clinical and economic burden. It is important that we all work together to make a real difference in nutritional care.

References 1 Mentes J (2006). Oral hydration in older adults: Greater awareness is needed in preventing, recognising, and treating dehydration. Am J Nursing 106(6): 40-49 2 Ahmed T and Haboubi N (2010). Assessment and management of nutrition in older people and its importance to health. Clinical Interventions in Aging 5:207 3 Stratton RJ, Hackston A, Longmore D et al (2004). Malnutrition in hospital outpatients and inpatients; prevalence, concurrent validity and ease of use of the â&#x20AC;&#x2DC;Malnutrition Universal Screening Tool (MUST) for adults. British Journal of Nutrition 4 Hiesmayr M, Schindler K, Pernicka E et al (2009). Decreased food intake is a risk factor for mortality in hospitalised patients: The Nutrition Day Survey 2006. Clinical Nutrition 28: 484-491 5 Malnutrition Task Force (2013). Malnutrition in Later Life: Prevention and Early Intervention. www.malnutritiontaskforce.org.uk/wp-content/ uploads/2014/07/CH-Prevention_Early_Intervention_Of_Malnutrition_in_Later_Life_Care_Home.pdf 6 Russell CA and Elia M. Nutrition screening surveys in care homes in the UK: A report based on the amalgamated data from the four Nutrition Screening Week surveys undertaken by BAPEN in 2007, 2008, 2010 and 2011 7 Elia M, BAPEN/NIHR. The cost of malnutrition in England and potential cost savings from nutritional interventions, 2015 8 Care Quality Commission. Time to listen: In care homes. Dignity and nutrition inspection programme 2012 www.cqc.org.uk/sites/default/files/documents/ time_to_listen_-_care_homes_summary_tag.pdf 9 Wolff A, Stuckler D and McKee M et al (2015). Are patients admitted from care homes dehydrated? A retrospective analysis of hypernatraemia and inhospital mortality J R Soc Med 108(7) 259-65 10 Meijers JMM, Halfens RJG, Wilson L et al (2012). Estimating the costs associated with malnutrition in Dutch nursing homes. Clinical Nutrition 31(1): 65-68 11 Elia M, BAPEN/NIHR. The cost of malnutrition in England and potential cost savings from nutritional interventions, 2015 12 NICE. Cost Savings Guidance 2015 13 Managing Adult Malnutrition in the Community: Including a pathway for the appropriate use of oral nutritional supplements (ONS). Produced by a multiprofessional consensus panel (2012). http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf 14 National Institute for Health and Care Excellence (NICE) (2012). Nutrition Support in adults. nice.org.uk/guidance/qs24 15 National Institute for Health and Care Excellence (NICE) (2006). Nutritional support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. www.nice.org.uk/guidance/cg32 16 NHS England. Guidance - Commissioning Excellent Nutrition and Hydration 2015-2018. www.england.nhs.uk/wp-content/uploads/2015/10/nut-hydguid.pdf 17 Managing Adult Malnutrition in the Community: Including a pathway for the appropriate use of oral nutritional supplements (ONS). Produced by a multiprofessional consensus panel (2012). http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf 18 Elia M, Stratton R, Russell C et al (2005). The cost of disease related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by BAPEN. www.bapen.org.uk/pdfs/health_econ_exec_sum.pdf 19 Stratton RJ and Elia M (2007). A review of reviews: A new look at the evidence for oral nutritional supplements in clinical practice. Clinical Nutritional Supplements 2:5-23 20 Cawood AL, Elia M, Stratton RJ (2012). Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Research Reviews 11(2): 278-296 21 Elia M et al. A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in community and care home settings Clin Nutr 2016 35 (1); 125-37 22 Stratton RJ, Green C and Elia M (2003). Disease-related malnutrition; an evidence-based approach to treatment. Oxford: CABI

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CONDITIONS & DISORDERS

PAEDIATRIC COELIAC DISEASE AND THE GLUTEN-FREE DIET Kate Roberts RD Freelance Dietitan Kate is a Freelance Dietitian with a wide range of clinical experience of working with adults and children from previously working in the NHS, her specialities are Diabetes and Allergies.

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

Coeliac disease (CD) is a systemic autoimmune disease which is caused by the immune system attacking healthy tissue due to the consumption of gluten.1 The villi which line the small intestine are damaged and flattened causing the typical gastrointestinal symptoms. Symptoms include: diarrhoea, constipation, wind, bloating, nausea, tiredness, weight loss or faltering growth, anaemia and hair loss. As these symptoms are quite general, CD can often go undiagnosed. CD is not always symptomatic and can also manifest itself as dermatitis herpetiformis, which is a skin condition also treated by a gluten-free diet.1 According to Coeliac UK,1 one in 100 people in the UK have CD; however, an estimated 24% of people are undiagnosed which is equivalent to nearly half a million people in the UK.1 According to serological studies, 1% of children (up to 18 years of age) have CD.3 Socially deprived children have a lower chance of being diagnosed. In children aged two and over, CD has tripled over the last 20 years.2

CD is not an allergy or an intolerance. It is more prevalent in children who have other autoimmune diseases such as Type 1 diabetes and autoimmune thyroid disease. Certain variants of the HLA-DQA1 and HLA-DQB1 genes lead to an increased risk of developing the disease. It tends to cluster in families; however, the inheritance pattern is unknown.4 SCREENING

According to the NICE guideline on coeliac disease, serological testing should be offered to children with any of the following signs and symptoms:5,6 • Persistent unexplained abdominal or gastrointestinal symptoms • Faltering growth • Prolonged fatigue

Figure 1: The areas of the bowel affected by coeliac disease2

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CONDITIONS & DISORDERS

The treatment for CD is a lifelong gluten-free diet. Dietitians are vital in providing education and support to families on diagnosis and beyond. • Unexpected weight loss • Severe or persistent mouth ulcers • Unexplained iron, vitamin B12 or folate deficiency • Type 1 diabetes, at diagnosis • Autoimmune thyroid disease, at diagnosis • First-degree relatives of people with CD If children have any of the following, NICE also recommends that they have serological screening:5 • Metabolic bone disorder (reduced bone mineral density or osteomalacia) • Unexplained neurological symptoms (particularly peripheral neuropathy or ataxia) • Persistently raised liver enzymes with unknown cause • Dental enamel defects • Down’s syndrome • Turner syndrome DIAGNOSIS

As mentioned above, a huge amount of children and young people have CD and are not diagnosed. See Figures 2 and 3 for details regarding diagnosis and when a duodenal biopsy is required. To avoid a false negative result, people need to continue consuming gluten daily for at least six weeks before any testing.6 This can be very difficult, especially with children, as it is difficult to explain, causes discomfort and can be distressing for parents and carers. The advice is to aim for 10g of gluten per day for infants and young children. Two meals per day containing at least 5g of gluten, such as wheat cereal, pasta or bread, should be sufficient. For all older 20

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children aim for 10-15g which equates to two larger portions of gluten containing foods; three meals would be preferable.7 It is possible to purchase gluten powder for parents who are struggling to increase their children’s intake sufficiently through a normal diet. This can be added to other foods such as yoghurts or porridge and is available online and in some health food shops. TREATMENT AND ROLE OF THE DIETITIAN

BSPGHAN and Coeliac UK recommend dietetic input at diagnosis, then three months after diagnosis, again at six months and annually after that. The treatment for CD is a lifelong gluten-free diet. Dietitians are vital in providing education and support to families on diagnosis and beyond. If a gluten-free diet is not followed, it can lead to nutritional deficiencies such as anaemia and osteoporosis as well as cancer of the small bowel and infertility.8 At the initial dietetic assessment it is important to assess growth and start to plot on a growth chart7 in order to monitor in future reviews. Education is essential and it is always useful to check that patients and their families understand the condition before going ahead with providing advice. The diagnosis can be a lot to take in and often, in my experience, patients need a recap on what CD is and especially what it is not (an allergy or wheat intolerance) before proceeding. It is best to do two diet histories. One for precoeliac disease to find out food preferences, in order to make patient-centred suggestions; and a history of the patent’s current diet to establish if they are already following a gluten-free diet. This also gives you an opportunity to assess their knowledge.

Figure 2: Outline stratagem for symptomatic children7

Figure 3: Outline stratagem for asymptomatic children with associated conditions7

Education should include the following topics: • What grains contain gluten • How to follow a gluten-free diet • Reading labels • EU legislation regarding food labelling and cross contamination Eating out can often prove to be difficult; however, legislation now states that caterers have to provide allergen information. This does not mean that they have to cater for people with CD. It is always best to contact caterers in advance to give them notice to provide a gluten-free meal. It may be necessary to educate the caterer on gluten-free food and cross contamination. Oats are a contentious issue, as often parents want to use them as a substitute, ideally they

should be avoided for a year, or until the child has reverted to the healthy state they were in before diagnosis.7 Lactose intolerance can sometimes occur if a patient’s gut has been damaged in the location that lactase is produced. This is usually temporary and will resolve a few weeks after a gluten-free diet is commenced. The charity Coeliac UK have local support groups which can be very useful for families trying to cope with the diagnosis. Often better practical advice comes from other families who have been through the same thing. It is good practice for dietitians to experience a gluten-free diet for themselves and to perhaps trial it for a week; it is easier to empathise with people when you have experienced it yourself. www.NHDmag.com March 2017 - Issue 122

CONDITIONS & DISORDERS Table 1: Reference Nutrient Intakes CALCIUM

IRON

0-1

525mg/day

0-3 months

1.7mg/day

1-3

350mg/day

4-6 months

4.3mg/day

4-6 years

450mg/day

7-12 months

7.8mg/day

550mg/day

1-3 years

6.9mg/day

4-6 years

6.1mg/day

7-10 years

Males 11-18 years

1000mg/day

7-10 years

Females 11-18 years

800mg/day

In the first appointment with a newly diagnosed Coeliac, it is normal to discuss prescription items and what people are entitled to. The Coeliac UK website has a Prescribable Products List.9 Gluten-free foods with ACBS approval9 • Bread/rolls • Breakfast cereals • Crackers and crispbreads • Flour/flour-type mixes • Oats • Pasta • Pizza bases However, over a third of Clinical Commissioning Groups (CCGs) are now restricting GPs prescribing gluten-free items due to demands to save money. Check out CCGs on the Coeliac UK website,10 they have a pretty nifty interactive gluten-free prescribing map of England. It is important to look out for signs of anxiety or depression in children and parents and carers. Living with CD can be a burden, as with any other long-term health condition.6 If you are concerned about mental health problems, ensure that you communicate with the multidisciplinary team and the primary health team, such as a GP, health visitor or school nurse. REVIEW

After three months, the dietitian should review growth and assess the diet again for adherence to a gluten-free diet. Usually, patients will start to feel better after a few weeks and at this review the patient will hopefully be doing just that. If children are still experiencing symptoms, a 22

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8.7mg/day Males

11-18 years

11.3mg/day

19 years +

8.7mg/day Females

11-50 years

14.8mg/day

50 years +

8.7mg/day

detailed diet history will be needed to explore potential contamination of gluten. If after a further three months symptoms continue, further investigations will be needed to explore whether the child has any other allergies or intolerances. Motivation to follow a gluten-free diet may wane and it is important to encourage patients and their carers to continue. It can be more difficult when children are asymptomatic, as they do not associate eating gluten with the disease. At the three-month review, it is important to review dietary intake of iron and calcium. Coeliac children do not need extra calcium or iron compared to other children; nevertheless, it is important that they are meeting their Reference Nutrient Intakes (RNIs). See table 1.11 Also ensure that children are getting enough vitamin D. Parents should be giving 0-1 year olds 8.5-10ug per day and everybody else (including adults) 10ug per day all year round.13 It is now thought that UK residents are unlikely to get enough vitamin D from UVB radiation from September through to April.12 CONCLUSION

Coeliac disease is a lifelong condition; all of the symptoms and risks to health can be reversed by following a gluten-free diet. It is vital that we as healthcare professionals support families to adhere to the gluten-free diet and promote healthy eating within it to optimise the health and development of children with CD.

CLINICAL

MALABSORPTION: AN OVERVIEW Emma Coates Registered Dietitian Emma has been a registered dietitian for 10 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.

For a list of useful reading please email info@ networkhealth group.co.uk

Malabsorption is the clinical term to describe any defects occurring during the digestion of food and the absorption of nutrients. Depending on the cause, the digestion or absorption of single or multiple nutrients can be affected. In lactose intolerance and the digestion of a single nutrient, lactose, is affected. However, for example, in coeliac disease, the digestion and absorption of several nutrients are affected. There are a wide range of symptoms related to malabsorption, with abdominal discomfort, bloating, flatulence, diarrhoea and weight loss being commonly reported by patients. Nutritional intervention is often required to manage malabsorption, including the use of exclusion diets, nutritional support and use of specialist nutritional products and/or supplements. In some cases, pharmaceutical intervention is also required. The intervention will depend on the definitive cause of the malabsorption.

Our bodies require a consistent supply of nutrients to function and maintain themselves. Nutrients are used in many complex pathways in order to produce energy, enzymes, hormones, proteins, cells, tissues and bone and to fight infections. The diet we eat supplies the essential nutrients to complete these vital tasks. WHERE AND WHEN DOES MALABSORPTION OCCUR?

The food we eat is digested in three stages. Table 1 shows each stage and gives examples of some of the conditions associated with those stages. It is important to understand the mechanism of malabsorption in order to realise the impact it may have on the

Table 1: stages of digestion and conditions causing malabsorption Luminal

Examples of conditions

Mucosal

Postabsorptive

Stomach acids, pancreatic enzymes and bile from the liver break down proteins, fats, and carbohydrates. At this stage micronutrients are released from the food.

At the brush border within the small intestinal epithelial cells, the nutrients are absorbed from the intestinal lumen.

Once absorbed, the nutrients are transported throughout the body via the circulatory and lymphatic systems to be utilised or stored.

Biliary atresia; Cholestasis; Cystic fibrosis; Lactose intolerance; Cancers including pancreatic cancer, lymphoma or stomach cancer; Pancreatic insufficiency or diseases; Zollinger-Ellison syndrome; Medications that inhibit stomach acid production, such as phenytoin.

Coeliac disease; Inflammatory bowel disease; Radiation enteritis; Decreased intrinsic factor production; Surgery, such as a bowel resection or gastric bypass; Short bowel syndrome; Scleroderma; GI tract infections including viral, bacterial and parasitic infections; Whipple disease; Tropical spruce.

Liver diseases or cancer; Lymphangiectasia; Intrinsic factor deficiency, e.g. pernicious anaemia; Blocked lacteals due to lymphoma or TB.

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Manage

MALABSORPTION with

Cow & Gate Pepti-Junior is designed to be easy to digest and absorb for cases of malabsorption in infants. It is specially formulated to: Enhance digestion and absorption: - Extensively hydrolysed formula1 - 50% MCT2 Promote palatability: - Whey based3-5 Reduce osmotic load: - Carbohydrate as glucose polymers6 - Low osmolality (210 mOsmol/kg H2O) For further information contact our Healthcare Professional Helpline on 0800 996 1234 or visit www.eln.nutricia.co.uk References 1. Keohane PP et al. Gut 1985;26(9):907-13. 2. Bach AC, Babayan VK. Am J Clin Nutr 1982;36(5):950-62. 3. Mabin DC et al. Arch Dis Child 1995;73(3):208-10. 4. Pedrosa M et al. J Investig Allergol Clin Immunol 2006;16(6):351-6. 5. Miraglia Del Giudice M et al. Ital J Pediatr 2015;41:42. 6. Shaw V (ed). Clinical Paediatric Dietetics. 4th ed. Oxford: Wiley Blackwell, 2015. Important notice Cow & Gate Pepti-Junior is a food for special medical purposes. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth, and as part of a balanced diet from 6 months.

CLINICAL

There are various stages of malabsorption depending on which point it occurs in the normal process of digestion and absorption within the gastrointestinal tract.

health of the patient. There are various stages of malabsorption depending on which point it occurs in the normal process of digestion and absorption within the gastrointestinal tract. Disruption of the normal digestive process can lead to malabsorption. The aetiology of the malabsorption will determine the type and severity of the symptoms and deficiencies observed. Also whether the situation is acute or likely to become chronic. FAT DIGESTION

During the luminal stage, long chain triglycerides are split into fatty acids and monoglycerides by lipase and colipase (pancreatic enzymes). They are then combined with bile acids and phospholipids, which form micelles. The micelles are transported through the jejunal enterocytes to be reconstituted to make chylomicrons when combined with protein, phospholipids and cholesterol. Chylomicrons are transported via the lymphatic system to ensure fats are utilised or stored. Medium chain triglycerides (MCTs) are absorbed directly by passively diffusing from the GI tract to the portal system. MCTs do not require any modification for absorption, unlike longer chain fatty acids. There is also no requirement for bile salts in order to digest MCTs. Patients experiencing malabsorption, or particular fattyacid metabolism disorders, can be treated with MCT as part of their diet or feeds due to the relative ease of MCT digestion by the body.

Steatorrhea, defined as excess fat in the stools, is a clear symptom in fat malabsorption. Patients experience pale, bulky and offensive stools, which are difficult to flush away. It is commonly observed in pancreatic insufficient cystic fibrosis patients when Pancreatic Enzyme Replacement Therapy (PERT) is not effectively managed or taken by the patient. Patients with Crohnâ&#x20AC;&#x2122;s disease, pancreatitis disease, short bowel syndrome and liver disease are highly likely to experience steatorrhea. When fats are unabsorbed, fat-soluble vitamins (A, D, E, K) and possibly some minerals will be trapped within the fatty molecules. This leads to deficiencies, which can be managed by supplementation of the affected nutrients and the use of enzyme replacement therapy, such as lipase replacement in cystic fibrosis and pancreatitis patients. The absorption of fats can be affected by bacterial overgrowth due to the deconjugation and dehydroxylation of bile salts. This has a limiting effect on fat absorption. Diarrhoea occurs due to the unabsorbed bile salts, which stimulate water secretion in the large intestine. CARBOHYDRATE DIGESTION

Carbohydrate and disaccharides digestion begins with the pancreatic enzyme, amylase and later the brush border enzymes, maltase, isomaltase, sucrase and lactase which continue to work on breaking down the complex sugars to create monosaccharides. The majority of the newly created monosaccharides are absorbed in the upper small intestine. Unabsorbed carbohydrates are fermented by colonic bacteria www.NHDmag.com March 2017 - Issue 122

Getting back on track starts with Glucodrate® is a tropical flavoured powdered blend of carbohydrate which is high in sodium and low in other electrolytes. For use in the dietary management of short bowel-associated intestinal failure and intestinal insufficiency in adults.

The focus of management in patients with intestinal failure is to reduce intestinal losses and thus prevent dehydration and electrolyte imbalances. This is achieved by restricting oral fluid intake and using a high sodium-glucose drink.1 Glucodrate is: • Available in a convenient, ready measured sachet • Palatable and well tolerated 2 • Provides 120mmol of sodium per 1,000ml of reconstituted drink A Nestlé Health Science Company ® Reg. Trademarks of Société des Produits Nestlé S.A. © Société des Produits Nestlé S.A. 2016. All rights reserved.

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Please contact your local Vitaflo sales representative for more information. Glucodrate is a food for special medical purposes and must be used under medical supervision. 1. Nightingale JM, L.-J. J. (2012). Management of patients with a short bowel. Artificial Nutrition and Support in Clinical Practice. J. Payne-James, G. K. Grimble and D. B. Silk, Cambridge University Press: 701 - 718. 2. Data on file

NHD 0317 March 2017

CLINICAL Table 2: Micronutrients and malabsorption Iron deficiency anaemia - often a manifestation of coeliac disease. Anaemias

Clotting disorders

Bone complications

Microcytic (iron deficiency) or macrocytic (vitamin B12 deficiency). Crohnâ&#x20AC;&#x2122;s disease or ileal resection - can cause megaloblastic anaemia due to vitamin B12 deficiency. Vitamin K malabsorption and subsequent hypoprothrombinemia - can lead to complications in blood clotting. Vitamin D deficiency - may lead to osteopenia or osteomalacia. Easy fracture of bones and bone pain. Secondary hyperparathyroidism - can be caused by the malabsorption of calcium. Malabsorption of vitamins B5 (pantothenic acid) and D - can cause generalised motor weakness

Neurological presentations

Peripheral neuropathy due to B1 (thiamine), B6 (pyridoxine) and B12 (cobalamin) malabsorption. Other complications can include night blindness (vitamin A), seizures (biotin). Loss of sensations such as vibration and position may be due to B12 (cobalamin) deficiency. B12 deficiency also causes breathlessness and fatigue. Hypocalcemia and hypomagnesemia, due to electrolyte malabsorption - can lead to tetany.

to create a variety of waste products, such as carbon dioxide, methane, hydrogen and short chain fatty acids including butyrate, propionate, acetate and lactate. The gases can be absorbed or excreted via breathing or flatulence. However, when malabsorption of carbohydrates occurs, excessive production of gas can cause abdominal distention, discomfort and bloating. Diarrhoea presents when there is an excess of the short chain fatty acids. Lactose intolerance (the appearance of clinical gastrointestinal symptoms after ingestion of lactose) is a common cause of the symptoms described above, with varying degrees of severity and longevity within the condition itself. The various types of lactase deficiency include congenital, primary and secondary lactase deficiency. Primary lactose deficiency occurs as lactase production decreases when the diet becomes less reliant on milk and dairy products. Usually, it presents after the age of two, but symptoms can take years to present, even into adulthood. Secondary lactase deficiency occurs as a result of a condition or surgery affecting the small intestine. For example, secondary lactose intolerance can occur in the short term after a gastrointestinal infection. A temporary exclusion of lactose from the diet will be required

with gradual reintroduction once symptoms are settled and the underlying condition is resolved or stabilised. Congenital lactose intolerance is a rare genetic disorder where little or no lactase is produced. A complete lifelong exclusion of lactose-containing foods and drinks is required in this instance. In primary and secondary lactase deficiency, there may be varying tolerance to lactose, therefore, individual assessment will reveal the level of restriction required. PROTEIN DIGESTION

Protein digestion is initiated by gastric pepsin within the stomach. It also stimulates release of cholecystokinin, which is vital for the secretion of pancreatic enzymes. A brush border enzyme, enterokinase, triggers trypsinogen, the precursor to trypsin. This pathway converts many pancreatic proteases into their active forms. Activated pancreatic enzymes act to hydrolyse proteins into oligopeptides. These are then absorbed directly, or hydrolysed into amino acids. When protein is malabsorbed, symptoms such as diarrhoea, abdominal discomfort and bloating may occur. Oedema and ascites are symptoms of severe protein malabsorption. www.NHDmag.com March 2017 - Issue 122

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CLINICAL Table 3: Examples of underlying diseases and treatment in malabsorption Disease/condition

Treatment

Coeliac disease

Gluten-free diet +/- vitamin and mineral supplementation, e.g. calcium, iron. Secondary lactose intolerance may occur and can be addressed with a temporary exclusion diet.

Lactose intolerance

Lactose exclusion diet with appropriate dairy replacements, e.g. lactosefree baby formulas in infants, suitable dairy alternatives and weaning advice for young babies. Appropriate calorie and calcium intake should be monitored across the life span.

Pancreatic insufficiency, e.g. in cystic fibrosis (CF) or pancreatic cancer

Protease and/or lipase replacement therapy. Advice and guidance regarding their use and dietary considerations should be provided. High calorie supplements may be required In CF patients, fat soluble vitamins are routinely prescribed. Enteral nutritional support is sometimes required.

Inflammatory bowel disease, e.g. Crohn’s disease, ulcerative colitis or pouchitis

Elemental feeds or liquid diets may be used to promote bowel rest and remission, administered orally or via enteral feeds. Vitamin and mineral supplementation may be necessary, e.g. regular vitamin B12 injections and iron supplementation. Corticosteroids and/or anti-inflammatory agents, such as mesalamine. Immunosuppressants, e.g. azathioprine and Infliximab. Probiotics may be considered, but there is limited evidence for their use; however, they may be useful in the management of pouchitis and ulcerative colitis.

Short gut syndrome

If there has been extensive intestinal disease or resection, parenteral nutrition may be necessary. High calorie supplements may be useful for some patients along with vitamin and mineral supplements, e.g. fat soluble vitamins, electrolytes, B12, iron. Antibiotics may be prescribed for bacterial overgrowth.

Liver disease, e.g. biliary atresia

MCT-based feeds and oil may be used in patients experiencing poor weight gain as a consequence of fat malabsorption. MCTs are more easily absorbed and don’t require the body’s usual process for fat metabolism, e.g. micelle formation is not required for absorption and they are transported via the portal route rather than via the lymphatic system. Fat-soluble vitamin supplements are required for patients with fat malabsorption. Oral and/or enteral nutritional support may be required.

Peripheral oedema is caused by hypoalbuminemia when there has been chronic protein malabsorption, or from loss of protein into the intestinal lumen. Ascites can develop when there are severe protein losses. Protein losses can be caused by extensive obstruction of the lymphatic system, seen in intestinal lymphangiectasia. As faecal nitrogen is difficult to measure, tests to confirm protein malabsorption are rarely performed. MICRONUTRIENT DEFICIENCIES

Malabsorption affects both macro- and micronutrients. Deficiencies of micronutrients can present as a collection or more selectively. Table 2 shows some of the effects caused by micronutrient deficiencies associated with malabsorption.

DIAGNOSIS

There is a vast array of tests performed to diagnose malabsorption and its underlying causes. A good general overview can be found at: British Society of Gastroenterology. Tests for malabsorption which is available at: www.bsg. org.uk/pdf_word_docs/malabsorbtion.pdf MANAGEMENT AND TREATMENT

When treating a patient who is experiencing malabsorption there are two approaches to consider: 1. Treat the underlying disease, e.g. coeliac disease. 2. Provide nutritional support to correct deficiencies, encourage adequate growth in children and prevent weight loss in adults. Table 3 shows just some examples of the underlying diseases and treatment in malabsorption. www.NHDmag.com March 2017 - Issue 122

IMD WATCH

Helen Rose Registered Dietitian, Interpreta Nutrition Helen is a partner in her own consultancy, having previously worked in the medical food industry and for the predecessor of the Food Standards Agency in nutrition research and regulatory affairs roles. Her specialism is food regulatory affairs in the infant and medical foods sectors.

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

EU LEGISLATION ON PRODUCTS USED IN THE MANAGEMENT OF INBORN ERRORS OF AMINO ACID METABOLISM Food for special medical purposes (FSMP) is an important part of the restrictive diet used to manage inherited metabolic disorders (IMD). This article focuses on those FSMP used in the management of infants and children with inborn errors of amino acid metabolism (IEM). These products are governed by legislation in the EU which has recently been updated, although there are remaining provisions within these rules that present issues for products such as protein substitutes (PS). Initiation of a modified diet at diagnosis aims to ensure the best outcome for infants and children with IEM. Natural dietary protein is severely restricted and a PS is provided to meet essential requirements for protein and other nutrients in order to achieve acceptable metabolic control. DIETARY MANAGEMENT IN EARLY INFANCY OF INBORN ERRORS OF AMINO ACID METABOLISM

In infancy, effective dietary management relies on a combination of This article restricted quantities of standard infant assumes that formula or breast milk and a specially the EU laws adapted infant formula. discussed, The specially adapted infant which entered into force in the formulas for the management of IEM UK in 2016, will (which are categorised as FSMP) continue to apply are based on amino acids rather in the UK in than natural whole protein. To take future. This may phenylketonuria (PKU) as an example, or may not be the specially adapted formula contains the case when no added phenylalanine, but provides the UK formally the other essential and non-essential leaves the EU. These rules will amino acids in combination with other continue to apply nutrients to satisfy requirements. in the EU. Dietary phenylalanine is restricted to 25% or less of normal intakes, and phenylalanine requirements are provided in the form of a standard infant formula or breast milk. 30

www.NHDmag.com March 2017 - Issue 122

CHANGES TO EU LEGISLATION AFFECTING SPECIALLY ADAPTED INFANT FORMULAS FOR IEM

In the same way as standard infant formulas, the specially adapted infant formulas are governed by EU legislation. Updated EU legislation was introduced in February 2016, with transitional arrangements in place until February 2020, governing the labelling, promotion and essential composition of FSMP, infant formula and followon formula. There are two separate Regulations,1,2 which replace similar rules that had been in place in the EU.3,4 In terms of the energy and macronutrient content of FSMP for infants, the new EU Regulation2 requires that FSMP for infants should be based on the composition of standard infant formula,1 whilst taking into account any adaptations required for the intended use of the product. For standard infant formulas, the maximum limit for protein has been reduced, from 3g/100kcal to 2.5g/100kcal and to 2.8g/100kcal for infant formula based on soy/hydrolysed protein. Protein requirements in IEM are typically higher than those for healthy infants. For example, recently published European clinical guidelines for the management of PKU,5 recommend that protein intake should supply the age-related safe levels of protein intake established by the World Health Organisation, with an additional 40% provided by L-amino acids. As a consequence, infant formula for the

management of IEM usually has a higher protein content to meet the increased needs of these infants. Under the provisions in the new EU legislation, an evidence based deviation from the compositional standard for infant formula would be accepted, as a higher protein content is necessary for the effective management of IEM in infancy. In the updated EU legislation, no changes have been made to the energy (60-70 kcal/100ml), fat (4.4-6g.0/100kcal) or carbohydrate (9-14g /100kcal) compositional standards for infant formula. The standards for essential fatty acids have been amended and docosahexaenoic acid (DHA) must be added to all infant formulas including specially adapted infant formulas. Under the previous provisions, DHA could be added up to a maximum limit, but there was no minimum limit. In common with the previous legislative provisions, the new rules have set compositional standards for vitamins and minerals. The updated minimum compositional standards for FSMP for infants are the same as those that apply to standard infant formula. The maximum compositional standards for many micronutrients are higher for FSMP for infants than for standard infant formula. This allows for the adaptation of products to address specific nutritional considerations for infants affected by the varying medical conditions for which FSMP are required. DIETARY MANAGEMENT IN CHILDHOOD

Beyond infancy, children with IEM continue to require specially adapted products to meet their nutritional requirements in the form of a PS, typically fortified with a wide range of vitamins and minerals. The weaning phase and feeding children with IEM can be especially challenging as food and, in particular, PS refusal, is common and the restrictive feeding choices are often burdensome for anxious parents.6 Given that the diet for IEM excludes sources of animal protein and many other foods are restricted, many nutrients are in limited supply and patients rely on supplementary sources of nutrients provided by their PS to meet their nutritional requirements. PROBLEMS FOR PS COMPLYING WITH THE COMPOSITIONAL STANDARDS

PS are FSMP and come under the same EU regulation as specially adapted infant formulas.2

These products are required to comply with a separate set of compositional standards for FSMP not intended for infants, with the caveat that compliance with the standards would not be required where the intended use of the product precludes this. This category of FSMP includes products designed for the dietary management of a wide range of medical conditions, in some cases to meet nutritional requirements in full, or, as in the case of PS, designed to supplement the diet. In common with the standards for FSMP for infants, these compositional standards are based on the amounts of nutrients provided per unit of energy. Whilst this approach is logical for FSMP for infants and products such as oral nutrition supplements, it presents compliance issues for products such as PS, as recommendations for PS intakes are based on protein requirements rather than energy requirements. In recent years, manufacturers have developed PS with reduced energy by decreasing the amount of carbohydrate these products contain amid growing concerns about the prevalence of obesity among patients. Most PS will provide quantities of many micronutrients in excess of the maximum compositional standards when assessed on the basis of the quantity of these micronutrients per 100kcal of the product.7 However, when the levels of micronutrients are assessed on the basis of protein requirements, as they are prescribed, the amounts provided by products should be nutritionally appropriate. This is an example of where the intended use of the product (to meet protein and micronutrient requirements) precludes compliance with compositional standards based on a productâ&#x20AC;&#x2122;s energy content. That said, it would seem to be a more sensible approach if the legislation made specific provision for these types of FSMP to ensure that products are safe and effective.7 Dietary management of IEM has been very successful in ensuring excellent outcomes for children affected by these conditions. In the UK, the new-born screening programme was extended in 2014 to include four new conditions (maple syrup urine disease, homocystinuria, glutaric acidurea Type 1, isovaleric acidaemia), allowing management of infants to commence in the first few weeks of life rather than following a period of acute illness, sometimes requiring intensive care. www.NHDmag.com March 2017 - Issue 122

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PAEDIATRIC

FALTERING GROWTH: CASE STUDY Kate Roberts RD Freelance Dietitan Kate is a Freelance Dietitian with a wide range of clinical experience of working with adults and children from previously working in the NHS, her specialities are Diabetes and Allergies.

Faltering growth (FG) was traditionally thought to be associated with low socioeconomic status; however, multiple studies have disproved this notion.3 There is a larger association between neglected children and faltering growth, but not faltering growth with neglect.3 FG is not a disease, it is a diagnosis of sub-optimal growth. Mild to moderate Faltering Growth (FG) is defined as a fall through two centile spaces on the WHO growth charts; a fall through three centile spaces indicates severe FG.1 There are different growth patterns to help health professionals identify FG:2 • Poor parallel lines

• Marked discrepancies in height and weight centiles • Discrepancies in family pattern • Retrospective rise • Saw tooth pattern The following case study is an example of dietetic input for a child identified with FG.

1 ASSESSMENT

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

Luke is a 23-month-old toddler who lives with his mum, stepdad and step-brother (seven months old). He has a complex social situation and is currently under a Child Protection Plan. Since birth he has had frequent episodes in hospital. He was diagnosed with FG twice before being referred to the dietitians; both times the Consultant Paediatrician concluded that his poor growth and small stature were probably genetic. Luke was referred to the dietitians at 23 months old, whilst he was an inpatient due to ‘weight and height way below 0.4th centile’. He was on zinc supplements and had a rash around his mouth and nappy area. At that point it was documented that his weight had dropped three centile spaces. Biochemistry Table 1: Biochemistry results from in-patient admission prior to dietetic review Age

1 year 9 months

Biochemistry

Result*

Serum zinc (umol/l)

10.4

9.8-20.6

Sodium (mmol/l)

136

135-145

Potassium (mmol/l)

4.9

3.5-5.5

Urea (mmol/l)

4.3

1.6-6.0

Creatinine Enz (umol/l)

30-50

Bilirubin (umol/l)

<20

Alkaline Phos (U/l)

130

35-353

ALT (U/l)

<50

Total Protein (g/l)

55-70

30-50

Albumin (g/l)

Normal range

Calcium (mmol/l)

2.40

Corrected Calcium (mmol/l)

2.48

*numbers in bold denote results which are not in the normal range

2.2-2.7 Table 1 continued overleaf

www.NHDmag.com March 2017 - Issue 122

PAEDIATRIC Table 1: Biochemistry results from in-patient admission prior to dietetic review (continued)

1 year 9 months

Globulin (g/l)

19-33

PO4 (mmol/l)

1.60

1.0-2.6

Haemoglobin (g/l)

114.0

105-135

Serum iron (umol/l)

3.4

12-25

Transferrin (umol/l)

35.0

20-40

Transferrin saturation (%) B12 (ng/l)

20-45

1594

190-910

Ferritin (ug/l)

12-55

Folate (ng/l)

11.9

4.6-20.0

*numbers in bold denote results which are not in the normal range

Summary of biochemistry: • Zinc levels are within the normal range; however, plasma zinc is a poor indicator of zinc deficiency due to tight homeostatic and control mechanisms.4 • Iron stores are likely to be normal, but are a signal of intercurrent illness. Serum iron is not a good indicator of iron deficiency. In terms of iron studies, low ferritin would confirm deficiency.5 Luke’s ferritin levels are slightly raised; however, acute inflammation can falsely raise levels and disguise iron deficiency.6 • Creatinine is slightly low which could indicate that he has low amounts of muscle mass, or simply that his kidneys are functioning well.7 • B12 levels are very high. Vitamin B12 is a co-factor for enzymes and high intakes have not been found to be toxic.8 The Reference Nutrient Intake (RNI) for Luke is 0.5ug per day.9 Nutritional history (taken at initial dietetic appointment) Luke was breastfed for one day; he was then started on Cow & Gate Stage 1 formula. Mum reports that it was taken well (although weight gain does not reflect this). Weaning commenced at six months, no issues, but he was fussy and disliked lumps. Mum reported that the Health Visitor (HV) recommended one pint of full cream milk (FCM) per day. Table 2: Anthropometric measurements Age

Weight (kg)

Centile

Length (cm)

Centile

Head circ (cm)

Centile

Birth

3.67

50th-75th

53.0

75th

35.0

50th

42.0

0.4th-2nd

2/52 For example growth charts for boy 0-4, please click here....

50th-75th

32+/52

6.81

2nd

65.0

0.4th-2nd

38+/52

6.71

0.4th-2nd

64.1

0.4th

49+/52

7.34

0.4th

66.0

below 0.4th

1y 1/12

7.40

0.4th

67.4

below 0.4th

1y 3+/12

7.85

0.4th

68.4

below 0.4th

44.2

2nd

1y 7/12

7.61

below 0.4th

1y 9+/12

8.30

below 0.4th

74.0

Well below 0.4th

45.0

2nd

www.NHDmag.com March 2017 - Issue 122

2 IDENTIFICATION OF NUTRITION AND DIETETIC DIAGNOSIS Faltering growth due to unknown causes, evidenced by a drop through three centile spaces on growth chart and weight and height below 0.4th centile. Aims: 1. Improve the quality and quantity of Luke’s oral intake to enable him to meet his estimated nutritional requirements required for catch-up growth and development. 2. Investigate whether anything medically, behaviourally or socially is preventing Luke from absorbing the nutrients he is consuming or whether he is receiving enough nutrients. Objectives: 1. Provide education to Luke’s parents on increasing the calories and protein of Luke’s diet through food and drink fortification.10 2. Monitor Luke’s weight monthly to assess if increased calories and protein are enabling catch-up growth as desired.11 3. Establish if Luke has any symptoms which could indicate any malabsorptive condition at the first consultation through speaking to his parents and looking through the medical notes. Initial dietetic assessment: Age: 1 year 10 months Weight two weeks before: 8.3kg (below 0.4th centile), length: 74cm (well below 0.4th). Luke appeared slim and pale in complexion his conjuctiva were not well perfused; his younger brother appeared to be thriving. Table 3: Reported diet history* BF: Rice Krispies/Weetabix/Ready Brek with full cream milk (FCM), double cream or Carnation milk plus cup of water and 4oz FCM MM: Fruit pot plus ½ crumpet with butter or crackers and cheese L: Homemade veg soup or ¼ cheese spread and ham sandwich or 1 slice toast and ½ can of beans plus cheese or small jacket potato with beans. Tomatoes or carrot sticks MA: Yoghurt mixed with double cream + berries EM: Fish in sauce, mash and broccoli or spaghetti bolognese or whatever the family is eating mashed up Bedtime: 8oz FCM Snacks: Milky Ways and chocolate digestives

Estimated oral intake from diet history - Energy: approximately 800kcals. Protein: approximately 9g *However Luke’s mum reported that he was at his biological father’s on the weekend of his admission and he’d only eaten custard and yoghurt.

Table 4: Daily estimated nutritional requirements9,12 Energy (EAR): 80 x 8.3 = 664kcals Protein (RNI): 1.2 x 8.3 = 9.96g Fluid: 100 x 8.3 = 830ml Calcium (RNI for 1-3 years): 350mg/day Iron (RNI for 1-3 years): 6.9mg/day Vitamin D (RNI for 1-3years): 10ug

www.NHDmag.com March 2017 - Issue 122

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PAEDIATRIC Nutritional assessment: • Exceeding macronutrient and fluid requirements according to diet history, although uncertainty over accuracy of diet history considering low weight. • Meeting calcium requirements due to high milk consumption.9 • Uncertain whether he is meeting his iron requirements; serum iron is low but this is not a good indicator of iron deficiency; serum ferritin is high but could be falsely raised due to infection.5,6 • Not meeting vitamin D requirements as not taking a supplement.9 3 PLAN AND IMPLEMENT NUTRITION AND DIETETIC INTERVENTION We discussed food fortification, plus nourishing drinks. Recipes were provided. Luke’s mum seemed very motivated to increase his weight. She reported that they have already been fortifying his foods and that the HV recommended one pint of full cream milk per day. Research has shown that encouraging frequent high energy meals and snacks is more effective than oral nutritional supplements for children.10,13 Agreed plan: • Continue with fortified meals and snacks.13 • Start giving nourishing drinks with fortified milkshakes rather than full cream milk to increase the protein and fat content. • Mum to request Healthy Start vitamin drops from HV.9 • Consultant to consider commencing iron supplements. • Arranged to review after four weeks. 4 MONITOR AND REVIEW Dietetic review at 1 year 11 months: Good weight and height increase, now on 0.4th centile for weight and following own line below 0.4th centile. Mum reports following advice and making fortified milk using our recipe sheet. Dad was not aware of the advice and, therefore, hasn’t been doing this. Mum and Dad have been keeping food diaries. Information was given to biological Dad regarding food fortification. Table 5: Current intake from food diary BF: 2 x Weetabix/Ready Brek with FCM and cream and raspberries/¼ banana MM: fruit and bread sticks (with cream cheese or chocolate spread) and 6oz fortified milkshake L: beans on ½ - 1 slice toast (with butter and cheese) MA: malt loaf with butter and yoghurt EM: Fish pie and peas or sweetcorn/homemade vegetable soup with cream/ spaghetti bolognese, pudding: apple crumble and custard Supper: 8oz fortified FCM milkshake Varied diet reported, with varied textures. Family encouraged with current intake and methods of food fortification. Discussed continued need for catch-up growth through nutrient-dense diet to encourage appropriate health and growth, with brain development. Parents appeared keen to continue with current dietary measures. Plan: • Continue nutrient-dense diet. • Review in one month Dietetic review at 2 years and 1½ months: Weight following 0.4th centile, height has stayed static and dipped slightly on the centile chart. Luke is now in nursery for three hours a day and Social Services are not involved as heavily. No concerns with bowels. Started iron supplements in June which Mum feels has increased his appetite and increased his energy levels. Luke was more lively in clinic.

www.NHDmag.com March 2017 - Issue 122

PAEDIATRIC Table 6: Diet history BF: Weetabix/Rice Krispies plus banana or apricots MM: fruit pots/chocolate roll/yoghurt (fruity Muller Corner), carrot sticks, chunks of cheese. L: sandwich/beans on toast/cooked dinner MA: similar to MM EM: pasta dinner (spaghetti bolognese/carbonara)/cottage pie/homemade fisherman’s pie. Puddings: fruit sponge and custard/Angel Delight/mousse Supper: porridge or cereal plus glass of fortified FFM Nutritional assessment: • Gaining weight along centile lines with slight catch-up growth, height static. Plan: • Continue nutrient dense diet. • Review in three months for weight and height check. 5 EVALUATION The initial aim was to improve the quality and quantity of Luke’s oral intake to enable him to meet his estimated nutritional requirements required for catch-up growth and development. In practice, this was dealt with by educating Luke’s mum on food fortification13 and to increase the protein and fat in the full cream milk he was already drinking by fortifying it and making it into milkshakes. His mum had described the intensive social input she was receiving and, therefore, I was confident that a month review would be suitable. The diet history she gave indicated that either she knew what she was supposed to be doing or had already started offering him more food. The diet histories all are high in calories and protein and are examples of good eating behaviours with frequent meals and snacks. It is difficult to determine the accuracy of this reporting and particularly in the initial assessment there was a mismatch between his growth and the amount his mother reported he was eating. Diet histories can easily be inaccurate due to over or under estimation or poor memory. Luke’s mum might have been saying what she thought she should or could have already made changes to his diet which had not had time to make an impact on his growth yet. This is an area which seems to be sparse in literature with respect to faltering growth. Since dietetic intervention commenced, his weight has returned to the 0.4th centile, but his height has continued well below the 0.4th centile line. I would have expected his height to increase in proportion with his weight. However, it was found in a longitudinal study that height stunting is chronic in nature and less easily corrected, whereas low weight can be corrected; children with faltering growth at six months were more likely to have a stunted height at three years of age.14 Therefore, we can expect Luke’s height to be slower to catch up. However, as he has just turned two years, he has changed from lying to standing measurement and height is slightly less than length.9 It is difficult to predict what weight and height is to be aimed for. Luke’s Paediatrician mentions catch-down growth in Luke’s notes and states that the timing and pattern of his drop down the centiles was indicative of him meeting his genetically determined potential height as his father had growing issues. Birth weights have increased over the last 80 years and infants born after 1970 had larger body sizes at birth which resulted in catch-down growth.15 There is doubt though as to whether Luke’s father was malnourished as a child which may have stunted his height; we would, therefore, have too low an estimate of Luke’s target height. In terms of what weight to aim for, the maximum weight centile between four to eight weeks of age is the best indicator for future weight centiles than the birth weight.16 Unfortunately, Luke’s maximum weight centile between four to eight weeks is not known, but you could hypothesise that it would be around the 25th centile if his weight loss was gradual from two weeks of age to seven months. However, if his height is to continue below the 0.4th centile, this would be out of proportion and he would have a high BMI. Therefore, it is important to monitor Luke to ensure his growth is in proportion and he is developing as expected. One of my aims was to investigate whether anything medically, behaviourally or socially was preventing Luke from absorbing the nutrients that he was consuming or receiving enough nutrients.

www.NHDmag.com March 2017 - Issue 122

Following the initial dietetic assessment, the medical notes were requested. The first assessment resulted in excellent weight gain through food fortification and from continued input from HVs, social workers and family support workers. It can be concluded again that there is no evidence of malabsorption. Luke’s biochemistry ruled out coeliac vdisease and he had no problems with his bowels which may signal fat or carbohydrate malabsorption. Extra calories, protein and snacks seem to have sufficed for aiding catch-up growth. There was a query over whether he was deficient in iron, but again this could have been dietary as opposed to internal losses. Luke’s vitamin B12 serum levels were high; it was also noted that the FSW reported that Luke’s mother has a history of not progressing her previous children on from milk and struggling with weaning. Vitamin B12 bioavailability is good from milk and it is one of the main dietary contributors from the UK diet for adults.17 This could indicate that when Luke was initially referred, his milk intake was high; however, his HV was encouraging his parents to give him a pint per day which could be enough for these raised levels. In summary, this has been a successful dietetic intervention resulting in Luke’s weight catching up to the centile line that he was previously following. His weight has not caught up as well as yet, but as discussed earlier, it could take longer to respond. Long-term follow-up will be required when Luke has reached his target weight and height. It will be important to re-educate him and his family and encourage healthy eating and activity to try to prevent a high BMI with its associated risks in the future. A prospective cohort study found that children with catch-up growth between 0-2 years had a higher BMI with more central adiposity in particular at five years of age.18 Table 7: Anthropometric measurements including post-dietetic intervention Age

Weight (kg)

Centile

Length (cm)

Centile

Head circ (cm)

Centile

Birth

3.67

50th-75th

53.0

75th

35.0

50th

65.0

0.4th-2nd 42.0

0.4th-2nd

2/52

50 -75 th

32+/52

6.81

38+/52

6.71

0.4 -2

64.1

0.4th

49+/52

7.34

0.4th

66.0

below 0.4th

1y 1/12

7.40

0.4th

67.4

below 0.4th

1y 3+/12

7.85

0.4th

68.4

below 0.4th

44.2

2nd

1y 7/12

7.61

below 0.4th

1y 9+/12

8.30

below 0.4th

74.0

Well below 0.4th

45.0

2nd

1y 10/12

8.52

below 0.4th

1y 10+/12

8.73

0.4th

75.0

below 0.4th

44.9

0.4th-2nd

1y 10+/12

8.80

0.4th

75.5

below 0.4th

2y 1+/12

9.26

0.4th

75.6

below 0.4th

2nd th

The shaded area indicates post-dietetic intervention www.rcpch.ac.uk/growthcharts

www.NHDmag.com March 2017 - Issue 122

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FOOD & DRINK

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

Ursula meets amazing people who influence nutrition policies and practices in the UK. MICHELLE BERRIEDALE-JOHNSON Director of Freefrom Food Awards Author & consultant on free-from foods Expert food historian

There was never a better time to be food allergic. EU regulations require clear information on the presence of any of 14 potential allergic ingredients on the labelling of all packaged foods and also for the provision of such information, when requested, for foods sold loose and also in restaurants and canteens. But, in addition to the improvement in the availability and accuracy of information, there has been a huge increase in the quality and variety of these ‘twin-foods’: those without a particular ingredient that may cause allergy in a few people. They are the new category of ‘free-from’ foods: a market that has been enjoying explosive growth of 15% yearly in the last decade. Perhaps not all of the increased interest in ‘free from foods’ (FFF) can be attributed to the activities of Michelle BerriedaleJohnson. But she is certainly the most prolific champion of this food sector and has done more than any other individual in the UK to bring together consumer and food industry interests to improve the quality and availability of FFF. She kindly invited me to her home, where we were a duet of seasonal coughs and sneezes, when even tea did not appeal. Her degree is in history, but it did not seem to offer any inspiring career options, so helping a friend with a busy catering company was the best way to pay urgent bills. Michelle enjoyed this, but it was hard work and there were many caterers competing for the outside venue business. She had the inspired idea to develop historic themed meals served in historic venues, and soon the most esteemed and

distinguished foodies demanded these food adventures. She said, “Of course these were not literal presentations of foods described in historic texts… rather they were ‘inspired-by’ meals. Most people would probably not enjoy more authentic historic menus.” Suddenly, Michelle was the expert on foods in previous times in both British and different cultures which allowed her to bring together her qualification in history and her many years of working in catering. She was funded to go on a speaking tour in the US and she wrote several books on historic meals. These included a trawl of Samuel Pepys with updated ‘recipes’ of food descriptions in his diaries, the British Museum cook book with recipes inspired by the various exhibits, and a book about possible foods consumed by Egyptian Pharaohs. Michelle was commissioned to write the ultimate book on the history of British food (aside from the original ultimate book by Sir Jack Drummond and Anne Wilbraham published in 1939). But fate shook some dice. One day in 1986, her husband had an acute allergic reaction. Medication cured the symptoms, but the trigger was a mystery. He was anxious not to experience this again, so tried cutting out various foods from his diet. At the same time, their young son had ‘itchy and scratchy’ skin that seemed relieved when dairy foods were eliminated. Although Michelle has no food allergies or intolerances, the Berriedale-Johnson relationship with their milkman ceased (amicably). www.NHDmag.com March 2017 - Issue 122

FOOD & DRINK The family drama led Michelle to a new interest in food allergy. There was a venture into the marketing of soya-based ice-cream and dairyfree chocolate, but effort and hassle exceeded praise and income, so this venture was dropped within three years. But her interest on the subject of food allergy was aflame and her writing fingers twitched. She decided to launch a newsletter for health professionals and food industry readers. Demand for the original Berrydales Special Diet News exceeded predictions and the print run for the later version, The Inside Story, was 36 thousand copies! All members of the British Dietetic Association received free copies with postings of Dietetics Today in the early-mid 90s, so it will be familiar to dietitians aged 45+. FOODSMATTER.COM

Michelle decided to focus her communications on the consumer and so launched a subscription newsletter: more than one thousand signed-up to pay £30 annually for food allergy/intolerance information updates. From 2007, this became the website www.foodsmatter.com, which today leads as an information forum on adverse food reactions. Michelle notes that, “about 65% of site visitors are now from the US. This was not planned, but may be just because of the larger population numbers. Also, there are more food allergy specialists in the US, so diagnosis is often faster.” In 2008, there was so much activity in the FFF sector that an obvious next-step was the development of industry awards. Tesco led the retailers, mainly through the ‘randomness’ factor of one of the buyers having a food allergic child, and turning this into a project. Michelle was the centre of huge excitement, to use Hollywoodstyle glamour, to drive an up-wind into small food companies, and the chef Anthony Worrall Thompson agreed to be the celebrity host for the event. In April last year, 300 enthusiasts gathered at the Royal College of Physicians to celebrate the ‘Freefrom Oscar’. There were winners announced for all of the 19 categories, so it was a long evening of celebration for many (alcohol may have been

consumed!). Companies pay £150 to enter each food product in one of 19 categories (or £90, if there are three of fewer staff). Michelle has about 80 judges to call on, who gather in small groups to assess and score the submitted samples. Of course, taste is-the-thing. But judges also evaluate ingredient lists, packaging and other quality issues. The ultimate winner in 2016 was Nutribix: a sorghum based gluten-free breakfast product. SO, WHAT WOULD MICHELLE SAY TO DIETITIANS?

There are disputes and tensions over the huge terrain of vague claims made on these subjects. Food allergy is easier to identify and treat, by elimination, than food intolerances. “But I wish dietitians would be more open to accepting the improved outcomes that many people get when they trial exclude certain food categories, mainly gluten or dairy, for short periods of time,” she said. “This should never be for more than three weeks, by which time there should be a clear better-ornot outcome. Of course, dietitians are the ones to witness the adverse effects of extreme and bizarre diet restrictions, but these are numerically very small, in balance to many people who benefit from the increased food choice awareness, and nearly always better diet quality, resulting from discussion about possible causes of adverse symptoms.” Michelle thinks that some of the unwellness symptoms people describe may just be the large amounts of dairy and/or wheat-based foods consumed by many people, rather than specific adverse effects of small amounts of these foods. “Are human adults really meant to be consuming lactation products from another mammal?” questions Michele. As I leave, Michelle gives me a copy of her justpublished booklet, FreeFrom all’Italiana, written with Italian cookery star, Anna Del Conte. Later in the day, judges and cooks will gather in her kitchen to sample first submissions for the 2017 award. “It will be chaos,” she says. My feeling is that this is how she likes things to be: very busy. If you would like to suggest a nutrition personality for Ursula to meet, please contact: info@ networkhealthgroup.co.uk

More information: www.michellesblog.co.uk & www.freefrommatters.com - information on all Michelle’s websites and awards www.foodsmatter.com - information website on food allergy and intolerance 42

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NETWORK HEALTH DIGEST

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SKILLS & LEARNING

EFFECTIVE MULTIDISCIPLINARY TEAM WORK Nikki Brierley Specialist Dietitian and CBT Therapist

An effective multidisciplinary team (MDT) is an essential part of delivering person-centred care and is associated with positive treatment outcomes. MDT working involves utilising the knowledge, skills and best practice from various disciplines and service providers.

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.

The key traits of successful MDT working have been identified as leadership, relationships, culture, clinical engagement, developing workforce, information, communication and commissioning. However, it is suggested that the most important guiding principle for MDT working is a shared commitment to delivering person centred and coordinated care. Care co-ordination is directly correlated with successful MDT working and improved long-term outcomes. It is suggested that key skills are required to undertake the role of care co-ordination, but that the clinical background or organisational base of the individual is less important. The elements required and the role of the care coordinator are summarised in table 1.

There is also an argument that the patient themselves is encouraged and supported to become their own care coordinator, with the aim of promoting independence and resilience in line with the underlying ethos of integrated care.1 IDENTIFYING AND OVERCOMING POTENTIAL BARRIERS

When introducing MDT working there are inevitable barriers which may present, it is important that these are acknowledged and overcome to ensure effective MDTs can be established and maintained. Indeed, part of the NHS 5 year forward view (2) requires that the traditional boundaries that exist between services are dissolved and the obstacles that prevent personalisation and coordination of health services be removed. Table 2 lists the potential barriers to MDT working.

Table 1: The role of care coordinator Form a proactive working relationship with the patient. Complete a holistic, person-centred assessment with the patient. Provide a central and continuous point of contact for the patient and professionals involved. Act as a key advocate for the patient if required. Assist the patient in the successful navigation of complex health and social systems. Demonstrate local knowledge of the range of health and care services. Take responsibility of care planning and ensure this takes place as agreed. Hold other providers within the care plan to account. Monitor and review care plans and agreed outcomes in partnership with the patient and evaluate outcomes. Provide direct care where appropriate. Adapted from NHS England MDT handbook, Jan 20151

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Table 2: Potential barriers to MDT working Cultural boundaries across pathways Systems and bureaucrat boundaries Funding and budgets Not looking beyond own expertise Focusing on professional intervention, in place of promoting independence, building competencies and self-care Changing patient profiles Adapted from NHS England MDT handbook, Jan 20151

DEVELOPING A TEAM

There is a wealth of information that indicates that developing a team is associated with a variety of positive outcomes, including improved service provision, innovation of service, enhanced patient satisfaction and increased staff motivation and mental wellbeing. It is recognised that teams go through different stages of development. Figure 1 demonstrates these stages and can be a useful tool in identifying why certain behaviours may be occurring and the feelings associated with these. There is also a variety of different models of team development that can improve self and team knowledge and encourage integrated working (i.e. Myers Briggs, Insight Discovery and Aston).

ASSESSING EFFECTIVENESS

Tools and frameworks to allow the assessment of MDTs have been developed and include establishment, ongoing development and regular review of effectiveness. Table 3 overleaf lists an example of the proposed indicators of effectiveness of MDTs. REFLECTIONS ON POSITIVE MDT WORKING

Drawing on personal experience of working within a specialist community eating disorder service, it is clearly evident that the effectiveness of the MDT is of paramount importance in promoting positive treatment outcomes. It is successful MDT working that ensures effective care planning and well informed clinical decisions. As such without

Figure 1: Bruce Tuckmanâ&#x20AC;&#x2122;s model of group development

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SKILLS & LEARNING Table 3: MDT effectiveness indicators Execution of task MDT structure and membership Meeting management Roles and functions Integrated care process Debate and discussion Trust within teams Individual/collective agreement Acceptance and accountability Attention to results Adapted from Bradford, Airedale and Craven; Integrated care for adult’s programme: Effective MDT development tool.3

an MDT approach it would not be possible to meet the complexities of this patient group. MDT working provides the ideal environment to greatly increase professional knowledge and significantly contributes to continual professional development. It facilitates a greater understanding of where the knowledge and expertise of specific professionals are required, where there is overlap and indeed where gaps in provisions can emerge. This improves collective understanding and allows solutions to be identified. The result of which can greatly increase overall job satisfaction, as each individual is recognised as a valuable and contributing member of team.

Establishing effective MDTs, and moving away from the limited practice of focussing on delivering individual professional expertise (i.e. providing dietary advice alone), requires the prioritisation of time. This time is needed for case discussions, team meetings, team development (i.e. Myers Briggs), information sharing and meeting with external teams. This investment however can result in significantly increased knowledge, skills and understanding, alongside enhance team functioning. Thus has the potential to not only greatly improve the patients experience, but also the experience of those professionals who are privileged to work as part of an effective MDT.

References 1 NHS England, Jan 2015, MDT Handbook: www.england.nhs.uk/wp-content/uploads/2015/01/mdt-dev-guid-flat-fin.pdf 2 NHS England, 2014, 5 Year Forward View: www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf 3 Bradford, Airedale and Craven; Integrated care for adult’s programme: Effective MDT development tool www.airedalewharfedalecravenccg.nhs.uk/ what-is-integrated-care

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READERSHIP SURVEY

NHD READERSHIP SURVEY 2016 RESULTS NETWORK HEALTH DIGEST

Thank you to everyone who filled in our Readership Survey towards the end of last year. We had a fantastic response which has given us a much stronger idea of the direction we are going in. Most of you feel that we are getting it right and all the comments and suggestions made are being carefully considered. Your input has been invaluable. The great news is that the majority of you who are reading Network Health Digest are making the most of your magazine and all the other resources we have on offer. Just under half of respondents have been reading NHD for five years or more and the majority (87%) read over 50% of its contents. 64% spend an hour or more reading NHD and almost 65% keep their issues for future reference. HOT TOPICS FOR OUR READERS

You have given us some great ideas for new topics which we will introduce as the year goes on, and topics of interest that we want to develop too, including within the Public Health remit, Catering Nutrition, Mental Health, Ethnicity and Technology. Here’s what you are

interested in most: • Malnutrition 56% • Obesity 51% • Skills and leaning 55% • Enteral and parenteral nutrition 50% • Diabetes 46% • IBS/IBD 44% The Survey has highlighted that many readers are not yet taking advantage of the NHD free subscription, even though they are eligible, or have forgotten their login details from our website to access the resources within the Subscriber zone. Nevertheless, our online resources at www.NHDmag.com are considered useful and informative to those who know that they are there!

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READERSHIP SURVEY Figure 2

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ONLINE RESOURCES

WEB WATCH Useful information, research and updates. Visit www.NHDmag.com for full listings. NICE GUIDELINES CEREBRAL PALSY IN UNDER 25S: ASSESSMENT AND MANAGEMENT NICE GUIDELINE (NG62) Published January 2017 This long-awaited guideline covers diagnosing, assessing and managing cerebral palsy in children and young people from birth up to their 25th birthday. It aims to make sure they get the care and treatment they need for the developmental and clinical comorbidities associated with cerebral palsy, so that they can be as active and independent as possible. It’s a valuable addition to for any healthcare professional working with this complex patient group. There is particular focus and recommendations on: • causes and recognition • multidisciplinary care and information and support • managing feeding and drooling problems • support with speech, language and communication • assessing and managing pain, discomfort, distress and sleep disturbances • information on other comorbidities, including mental health problems

• transition to adults’ services To read the full guideline visit: www.nice.org. uk/guidance/ng62

NUTRITION AND HYDRATION WEEK 2017 - WORLDWIDE AFTERNOON TEA Save the date for the Nutrition and Hydration

Week Global Tea Party for 2017 to be held on Wednesday 15th March 2017. This will be an afternoon tea party, which is celebrated around the world. In order to promote the week, afternoon teas will be served across a variety of health and social care settings. It’s also a great opportunity to show the work your organisation does every day and how nutritional intake can be improved. The event organisers are encouraging everyone to take part to support the week and demonstrate your commitment to improving nutrition and hydration. If you organise and hold a tea party during Nutrition and Hydration Week 2017, you can tweet photos to the event team @ NHWeek and use the hashtag #NHW2017. You can find more information and resources at www.nutritionandhydrationweek. co.uk/worldwide-afternoon-tea/

Turn to page 8 of this issue for more information on the week.

PUBLIC HEALTH ENGLAND CONSULTATION ON DRAFT SACN UPDATE ON FOLIC ACID A draft of the SACN update on folic acid is now available. This report updates the previous reviews of potential adverse effects of folic acid on specific health outcomes and its recommendations on folic acid fortification (2006; 2009). To read the full draft report visit: www.gov.uk/government/consultations/consultation-on-draftsacn-update-on-folic-acid

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STREAMLINING DIETETIC DISCHARGE - NEW RESOURCES The Dietetic Team at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) have recently undertaken a project to standardise their discharge communication to ensure clear, concise dietetic care plans are being communicated from the acute to the community setting. The project aimed to save dietetic and community healthcare professional time, whilst contributing to standardised care and practice and ultimately improve patient outcomes. The main objectives of developing the standard letter were to: • provide a concise dietetic report/summary including all relevant and appropriate information for a prescription request; • ensure patients meet ACBS criteria for an ONS prescription; • avoid errors in prescribing through providing sufficient information for GPs to electronically prescribe nutritional products, e.g. ONS volume, product, duration of prescription; • provide clear information regarding actions required by clinicians, as well as dietetic outcomes of the intervention and comprehensive follow up guidance. The team at GSTT worked closely with local GPs and consulted representatives from key professional and patient bodies in order to standardise their dietetic discharge letter. “We made sure we spent time with individual stakeholders throughout the process to ensure

that the letter could be adapted to the needs of their specialities,” explained Michelle Duffy, Senior Specialist Prescribing Support Dietitian at GSTT. “This was crucial to ensure that the letter gained the visibility it needed to establish it as the ‘standard’ for all dietetic teams across the Trust.” The team also developed a ‘Standard Operating Procedure’ (SOP) to support the letter and promote ease of use by dietitians. The SOP is designed for use by any dietitian who is new to using the letter, in order to maintain the format, content and standard of communication going forward. It provides guidance on how to complete and adapt the letter; ensuring relevant ‘boxes’ are included or deleted as appropriate. Since introducing this standard dietetic discharge letter into the Trust, the team has seen a notable reduction in queries from GPs on prescription, thus minimising their time burden and helping to improve patient care by avoiding delays in prescriptions. The team at GSTT are keen to share their work with other healthcare professionals and have made a copy of the letter and SOP freely available via the Managing Adult Malnutrition in the Community website - www.malnutritionpathway.co.uk/ health-resources - see discharge resources section. Teams interested in using the letter in their Trust/ department should contact natasha.mir@gstt.nhs.uk and michelle.duffy@gstt.nhs.uk

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DATES FOR YOUR DIARY Allergy and Free From Show Scotland 10th to 12th March -Glasgow www.allergyshow.co.uk/ Nutrition and Hydration Week 13th-19th March www.nutritionandhydrationweek.co.uk/ Diabetes 2 (D24D02) 15th/16th/17th March - University of Nottingham Email: Katherine.lawson@nottingham.ac.uk www.nottingham.ac.uk/biosciences National Salt Awareness Week 20th to 26th March www.actiononsalt.org.uk/awareness/ The moment for plant-based eating is now 24th March - Brussels www.alprofoundation.org/20-years/ BDA Vision 30th March - Birmingham www.bda.uk.com/events/home

UNIVERSITY OF NOTTINGHAM SCHOOL OF BIOSCIENCES Modules for Dietitians and other Healthcare Professionals • Paediatric Nutrition (D24PAN) 9th/10th March and 4th/5th May 2017 • Nutrition Support (D24BD2) 19/20th April and 26/27th April

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’. World Health Day 7th April www.who.int/campaigns/world-health-day/2017/en/

DIETETIC JOBS

PAEDIATRIC DIETITIAN ADVISOR, NSPKU (UK) LTD The National Society for Phenylketonuria (NSPKU) is looking for a Specialist Registered Dietitian (working at Band 7 level) with several years’ experience in caring for babies and children with PKU and their families. This post works in partnership with the NSPKU’s adult dietitian with an emphasis on developing stronger links between the NSPKU and the metabolic clinics around the UK. The post is classed as self-employed with an average of 20 hours per week, initially for a six-month trial period, with some weekend work. As a representative of the Society you will be expected to respond and deal practically with matters arising from the NSPKU telephone helpline and email enquiries (this may lead to home or school visits); write articles for professional and lay publications; deal

dieteticJOBS.co.uk

To place a job ad here and on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) with the media; organise the diet for study days and conferences; co-ordinate the scientific programme/ speakers for the annual family conference; respond co-ordinate research; give presentations; keep PKU information up to date and attend numerous professional meetings e.g. SSIEM, BIMDG, ESPKU. To apply or for further information please contact Caroline Bridges by email: info@nspku.org or telephone 030 3040 1090. Closing date: Friday 31st March 2017 - www.nspku.org

A wealth of useful dietetic resources www.NHDmag.com

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THE FINAL HELPING Neil Donnelly

Neil is a Fellow of the BDA and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders.

Last autumn, I was invited to attend a wedding in Portugal. I was informed that a longstanding female school friend of the groom was also attending the wedding and had met me before. The night before the big day, I was reintroduced to the groom’s friend, Anne. Some 30 years earlier, Anne had come to Blackpool to do her catering placement and had spent two days ‘with the dietitian’. She was now the Principal Lecturer of Food and Nutrition at Manchester Metropolitan University. The wedding ceremony was held outside on a lovely sunny day and after several glasses of champagne, Anne asked if I would like to be a guest speaker at a Careers Day next year. “Of course!” I replied. The conference was in February this year and I was asked to be the opening speaker. Most certainly I would! I was out of practice, however, but as I was asked to talk about my career as a dietitian and the possible changing landscape, I knew it would be fine. These were my thoughts whilst preparing for the event: Let me see now, where are all those slides I took when I started my first job on a Food Consumption Survey in Zambia? How about those overheads I prepared for my student presentations. Looks like I’m going to have to revise my PowerPoint skills. Shall I start off by telling them how much I owe to Muriel Westland, who despite my not getting the grades asked for, accepted me onto the Nutrition and Dietetics Honours degree course at Surrey University in 1966! I also thought I would refer to my six-month hospital placement in Glasgow when I saw for the first time a patient on a ward with an Eating Disorder. She was a teenage girl on a tube feed surrounded by photographs

of her smiling with family and friends. It was meeting her that impacted greatly on my career path. Then of course I would mention my Final Year University Project. It was in 1969/1970 and the title was ‘Fitness and Fatness’. My fit male subject group were players from Chelsea Football Club and I visited the Club on four occasions to carry out my fitness measurements using the Harvard Step Test and fatness measurements using skinfold callipers. As I was trawling through my slides and overheads, I came across a bag which I thought contained papers from my first job as a VSO in Zambia. It wasn’t. It was my long lost Final Year Project. I spent the next half an hour absorbed in ‘Physical Fitness and Body Fat of Trained and Untrained Subjects’ by Neil Donnelly June 1970. My external assessor was Elsie Widdowson, which made it all the more memorable. To add to my delight at that time, the Chelsea Manager, Dave Sexton was interested to hear that the trained female group, who were dancers from the Royal Ballet School, were fitter on average it seemed than professional footballers! A few changes, seemingly, were then made to the training regime and by the end of the season, Chelsea had won the FA Cup for the first time after an extra time Cup Final replay! The career presentation went very well and seemed to draw some favourable comments on the Man Met social media twitter feed. What more could I ask. www.NHDmag.com March 2017 - Issue 122

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