Network Health Digest - April 2017 by NH Publishing Ltd

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

NHDmag.com April 2017: Issue 123

Follow-on formula: friend or foe? SPORTS NUTRITION JUICES & SMOOTHIES ORAL NUTRITIONAL SUPPLEMENTS GLYCOMACROPEPTIDE

Nasogastric feeding Pages 16 to 19

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FROM THE EDITOR

WELCOME . . . Emma Coates Editor

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

Welcome to the April issue of NHD. March proved to be a busy and exciting month for Dietetics with Nutrition and Hydration Week (13th-19th) producing an explosion of tweets and Facebook posts to promote the many innovative ways to raise awareness and improve patient intakes. Some of my particular favourites were the use of an ice cream machine for a twist with oral nutritional supplements; high calorie, high protein mocktails, complete with mini umbrellas and decorations; then there were the fantastic displays, stands and competitions to win free meals or smoothie makers. The whole week was a true celebration of our work and demonstrated the solidarity we have as a profession in promoting the very best for our patients, their families and each other. Fantastic work and a high five to everyone who got involved. I’m already looking forward to Dietitians Week in June (12th-16th), this year, themed around evidence and expertise, highlighting the importance of evidence-based approaches to nutrition. In this month’s issue, we bring you a broad section of evidence-based articles and features to keep your knowledge and skills’ engine running. If nutrition support is your thing, Sean White and Anne Mensforth give us an overview of nasogastric feeding, focusing on the potential problems associated with feeding adult patients in the community setting and how to manage them, discharge planning and the importance of specialist teams in this patient group. You’ll also discover an article with a case study written by myself, looking at ONS in nutritional support. In Paediatrics, follow-on formulas may be useful for some small children. Judy Paterson, Paediatric Dietitian, takes us through the pros and cons of this product group in our Cover Story.

Priya Tew RD dives in to the world of juices and drinks, revealing what to consider when choosing juices, smoothies or plant waters. What are the health benefits, if any? And are they as virtuous as they seem? We’re also pleased to share an interesting Sports Nutrition article from Claire Chaudhry RD, discussing why athletes are at risk of poor oral health and how to advise and manage this accordingly. There have been some exciting developments in the world of PKU over the last few months and we’ve asked two prominent metabolic dietitians to discuss and explain the news. Paula Hallam RD takes us on a new journey through GMP (Glycomacropeptide) and its role as an alternative protein source for PKU. Suzanne Ford RD (NSPKU adult dietetic advisor) talks us through the recently published and long awaited ESPKU guidelines and what they mean for adult PKU patients. We also have our regular contributions from Dr Emma Derbyshire, with Food for Thought and Ursula Arens who shares a book review, Caring About Hunger by George Kent, which focuses on world hunger and the daily struggle for food globally. In her F2F column this month, Ursula meets Moira Howie, Nutrition Manager at Waitrose, to discuss her work, team and thoughts. You can help yourself to a little more NHD goodness in NHD Extra online, with a CPD article from Yours Truly on developing perspectives on learning and development. We hope you enjoy this issue. Emma www.NHDmag.com April 2017 - Issue 123

CONTENTS

11 COVER STORY Follow-on formula: friend or foe?

News

Face to Face

Latest industry and product updates

with Moira Howie, Company Nutritionist, Waitrose

16 Adult nasogastric feeding in a community setting

21 ONS Their use in nutrition support

37 Glycomacropeptide An alternative protein source for PKU

43 SPORTS NUTRITION Athletes and oral health 46 Book review Caring About Hunger 48 Web watch Online resources

and updates

28 Juices and smoothies What are the current trends?

33 IMD WATCH European guidelines for adults

50 Events & courses, dieteticJOBS Dates for your diary and

job opportunities

51 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 April 2017 - Issue 123

ISSN 2398-8754

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NEWS

FOOD FOR THOUGHT

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.

DON'T OVERLOOK CHILD OBESITY The UK’s plan of action to reduce childhood obesity ‘missed an opportunity for global leadership’, according to a new report in The British Medical Journal, generating an ‘immediate outcry from the medical and public health communities, who had hoped for much more’. One of the most significant omissions was reference to the recommendations made in the World Health Organisation’s Commission on Ending Childhood Obesity (ECHO), published in January 2016, which included evidence based interventions, such as: • an industry levy on sugar sweetened beverages; • clearer food labelling; • nutrient profiling to identify healthy and unhealthy foods; • promotion of physical activity in schools. By failing to recognise that overweight and obesity in children and young people are driven by multiple modifiable biological, behavioural, environmental and commercial factors, a major opportunity has been lost for effective prevention. They add that the concept of obesity prevention as predominantly a matter of personal or parental responsibility has been particularly unhelpful, with voluntary actions, ranging from individual’s efforts to lose weight to industry development of healthier products ineffective in tackling the problem. They suggest a wider global alliance is needed, with emphasis on a life course approach and led by an international alliance of healthcare organisations which the ‘UK government would work with to build on their plan for action and develop it into a strategy for childhood and future societal health’. In addition, there needs to be effective training of a wide range of health and education professionals in how to engage parents, children and young people with the issue of overweight and obesity. Lastly, there is a need for healthcare professionals to use their national and global professional networks to coordinate action between sectors, including education, industry, government and the public. So, let’s not forget about the significance of childhood obesity, even though the Government grossly underestimated the importance of tackling this. For more information, see: Hanson M et al (2017). British Medical Journal. Vol 356: j762. Available at: www.bmj.com/content/356/bmj.j762/rr-3.

www.NHDmag.com April 2017 - Issue 123

NEWS MOVING TOWARDS 10-A-DAY? Data from the latest National Diet and Nutrition Survey reveals that intakes of fruit and vegetables remains low, with only 27% of adults aged 19-64 years and 35% over the age of 65 years meeting the 5-A-Day recommendation. Despite this, new research now suggests that we may need to strive for 10 portions of fruit and vegetables each day to lower our risk of chronic disease. The article published in the International Journal of Epidemiology received much publicity and analysed data from 95 prospective studies measuring fruit and vegetable intakes and associated risk of cardiovascular disease, total cancer and all-cause mortality. Results revealed a reduction in disease and all-cause mortality with each 200g/day increase in fruit and vegetables. A daily intake of 800g (about 10 portions) was linked to: • a 33% reduced risk of stroke; • a 31% reduced risk of all-cause mortality; • a 28% reduced risk of cardiovascular disease; • a 24% reduced risk of coronary heart disease; • a 14% reduced risk of total cancer. Scientists concluded that an estimated 5.6 and 7.8 million premature deaths worldwide could be attributed to fruit and vegetable intakes of less than 500 and 800g/day respectively. It should be considered that the food frequency questionnaire used in this study could have ‘overestimated’ intakes. Nevertheless, there is some value in these findings, indicating that we may need to take another look at 5-A-DAY guidelines and ways to target and boost intakes to align with these. For further information, see:

Aune D et al (2017). International Journal of Epidemiology 1-28.

VITAMIN D AND RESPIRATORY INFECTIONS Over the past decade, interest has grown in the physiological importance of vitamin D outside of bone health and calcium homeostasis and there is mounting evidence to suggest that it plays a beneficial role in the prevention and treatment of a wide range of diseases, including respiratory infections. New research published in The British Medical Journal analysed data from 25 randomised controlled trials comprised of 11,321 participants aged <95 years. Findings showed that vitamin D supplementation reduced the risk of acute respiratory tract infection among all participants with strongest effects in those with lowest vitamin D levels. These are important findings and worthy of further exploration, given that the recent National Diet and Nutrition Survey revealed that one in five adults had low blood levels of vitamin D and highlights the need for further exploration into the effects of food fortification to improve the health of the general population. For more information, see: Martineau AR et al (2017). The British Medical Journal; 356.

IRISH IODINE INTAKES Iodine is required for the synthesis of key thyroid hormones, which in turn are necessary for infant nerve and brain development during fetal and early postnatal life. New work published in The British Journal of Nutrition has now examined dietary iodine intakes and analysed iodine status of 1,106 participants using the National Adult Nutrition Survey (2008-2010) and Irish Total Diet Study findings. Results revealed that iodine levels were sufficient in the majority of the adult population; however, 77% of women of childbearing age (aged 18-50 years) did not meet the estimated average intake requirement set for pregnant women. These are significant and much needed findings highlighting that iodine shortfalls are apparent amongst women of childbearing age. Continued research on other UK and European populations is now needed. For more information, see: McNulty BA et al (2017). British Journal of Nutrition; 1-10. www.NHDmag.com April 2017 - Issue 123

F2F

FACE TO FACE Ursula meets: Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. Shas been a columnist on nutrition for more than 30 years.

Ursula meets amazing people who influence nutrition policies and practices in the UK. MOIRA HOWIE Manager - Nutrition @ Waitrose Dietitian

Moira has been the company nutritionist for the predominantly south-east-facing retailer Waitrose for 12 years. We had arranged to meet in the cafe of one of their new branches behind Kings Cross station many weeks ago and randomly, there were suddenly many reasons why meeting Moira then and there was so exciting. It was the Retail Week Conference and the news was full of commentary from the annual trade conference. Many changes were predicted: the smallest but fastest growing heavy-discounters were challenging the larger and moreestablished retailers. There is battle and tension between made-of-bricks premises and online services and while Brexit will not alter the need to eat, it will create food inflation and put huge pressures on currently comfortable trading arrangements for the whole industry. The Kings Cross branch of Waitrose is not like any other supermarket. It is next to Central Saint Martin’s school of Art and Design, so caters to many image conscious students. One of these, a young student architect also sitting in the cafe, was constantly leaning over, desperate to share our dietetic discussions. While we were sipping tea, there was a media flurry: snapping pictures of a banner proclaiming ‘6%’ (the just-announced annual salary bonus given to all partners of the John Lewis Partnership - a unique benefit of the co-ownership model that John Lewis and Waitrose share). And then

www.NHDmag.com April 2017 - Issue 123

a group of 30 camera-clicking visitors also entered the shop: they were a specialist tour group of shop-owners from Brazil seeking retail ideas and inspiration. Dietitians seeking retail ideas and inspiration need to meet Moira. She is dedicated to the improvement of public health through the communication of the healthy diet, and enjoys the very special privileges of being able to engage daily and very closely with those who influence decisions of what does and does-not appear on supermarket shelves. Moira did not start her career in the food and diet arena. After school she worked as a cardiology technician in a hospital in Blackpool. She trained on the job for two years and obtained a Higher National Certificate (HNC) in medical physics and continued to work in this area for seven years. “I really enjoyed the daily tasks, but I was frustrated that much of the suffering I observed could have been prevented.” A colleague who agreed with her and gave her much support, was none other than our own NHD columnist Neil ‘Final Helpings’ Donnelly. “You should be a dietitian,” he had suggested. After a two-year side-move as a school science technician, Moira signed up for a degree in Biology with Nutrition and Dietetics at the North London Polytechnic (now London Met). She graduated in 1992 and jumped straight into employment working in a health promotion unit in Chelsea.

Disease prevention in every dietary way was her role, and included projects with local schools, local employers and local NHS clinics. There was a phone call for her one day (following a very short TV interview segment). “Join us: we need you,” said the international PR company. Moira was comfortable with the brief and the clients, so for the next five years, Moira enjoyed the international reach that BursonMarsteller allowed her. Here, her main project was the public communication for the Unilever brand Flora, about the benefits of reducing saturated fat in the diet and replacing with polyunsaturates. In 2000, Moira was approached by the retailer Safeway to set up their nutrition department. This was the start of more forward thinking for the business and its customers. Moira devised healthy-meal specifications and guided communication and marketing concepts supporting consumers to make better diet choices. When the retailer Morrisons purchased Safeway, they consolidated the technology team, but Moira thought it was time to move on. She really enjoyed the retail environment and Waitrose was very happy to welcome a preformed retail-expert nutritionist, particularly one who had been nominated in 2002 by her BDA peers in a Sunday broadsheet as one of the top 10 dietitians in Britain in bringing influential change. She heads a team of two nutritionists, and always has a one-year industrial placement for a student studying nutrition or dietetics. So, there are four clever heads that gather to plan and implement nutrition direction and healthier formulation for Waitrose products. She leads the company nutrition strategy to ensure it reflects government policies and science-based research and translates this into product development. Waitrose has led the field in quiet salt reduction of foods and has also been a pioneer in the

launch of chicken that contains high levels of omega-3 fatty acids, as well as in the promotion of unglamorous beans and pulses. But she also has to be ever-alert to consumer perceptions of quality and health. In fact, the latter is one of her concerns: many foghorn blasts come as a result of diet assertions by young and beautiful promoters of books and video blogs. The zephyrs of sound science from dietitians seem to get lost in consumer concerns over diet, leading to distorted demands on retailers. “I wish dietitians would be more assertive in communicating dietary principles. New media and marketing tools are also there for their use, but they seem hesitant to reach out and join public debates.” Moira is also critical of the constant eat-less messages that push out some eat-more themes. The SACN carbohydrates report recommended a reduction in population intakes of free sugars, but lost from public discussion was the equally dramatic recommendations that population fibre intakes should be increased to 30g. “Dietitians should champion and promote broader themes, including consuming more wholegrain foods, and replacing some meat in the diet with plant protein foods such as beans and pulses.” Moira can do a lot to promote healthy diet concepts to Waitrose customers, as every nutritionist working in retail knows, ‘the customer is always right.’ Despite my glum suggestion that population diet change was as many steps back as forward, Moira insisted that so much had been done, and would be done in the future. “I’ve always been a glass-half-full person,” she said. I looked at my three-quarters-empty cup of cold tea, but thought that she was more than that; fully-full and overflowing with positivity. Moira is the perfect dietitian to combine the daily tensions between commercial reality and driving healthy food choices for shoppers.

If you would like to suggest a F2F date

(someone who is a ‘shaker and mover’ in UK nutrition) for Ursula, please contact:

info@networkhealthgroup.co.uk www.NHDmag.com April 2017 - Issue 123

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

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

Important notice: Breastmilk is best for babies. Nutriprem Breastmilk Fortifier is a nutritional supplement designed to be added to expressed breastmilk for feeding preterm and low-birthweight infants. Nutriprem Protein Supplement, Hydrolysed Nutriprem, Nutriprem 1 and 2 are foods for special medical purposes. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed Nutriprem, Nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and lowâ&#x20AC;&#x201C;birthweight infants. Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50:85â&#x20AC;&#x201C;91.

COVER STORY

FOLLOW-ON FORMULA: FRIEND OR FOE? Judy Paterson Registered Dietitian, Hampshire Hospitals NHS Foundation Trust

Judy has worked as a Paediatric Dietitian for two years in general paediatrics and neonates, with a special interest in gastroenterology. She is passionate about evidencebased nutritional care and promoting the role of the dietitian.

Follow-on formula milk (FOFM) is targeted at infants starting to introduce complementary foods from six to 12 months of age. This article discusses the definition, purpose and suitability of FOFM for infants and the effects of the marketing of such on breastfeeding in the UK. The legal definition of FOFM from the Department of Health (DH) is: ‘foodstuffs intended for particular nutritional use by infants when appropriate complementary feeding is introduced and constituting the principal liquid element in a progressively diversified diet of such infants.’1 The main difference between first infant formula milk and FOFM is the iron content.2 The other subtle differences include vitamin D, protein and carbohydrate content (see Table 1). Prior to 2014, FOFM had higher protein levels which are associated with risks of obesity.2-4 As a result of guidance from the European Food Safety Authority (EFSA), protein content has been reduced in recent years,5,6 but is still higher than estimated in breastmilk, due to disparities in amino acid profile between breastmilk and bovine milk.2-5 Regulations require infant formula to contain an available quantity of each amino acid at least equal to that found in human breastmilk.3-6 FOFMs contain more carbohydrate and are sweeter than first infant milk. Two FOFMs (see Table 1) also contain maltodextrin which reduces their sugar content, although it is not clear whether this also reduces their sweetness. Finally, the cost of FOFM is marginally higher than first infant milk in the region of £0-2 per month.

Goats’ milk based FOFM, which was previously excluded from the European market due to safety concerns, became available in the UK market following a revision of guidance by EFSA in 2012.7 These have not been included in Table 1 overleaf. However, it is likely to present additional challenges for healthcare professionals with respect to claims of being ‘free from cows’ milk protein’, whilst also being more expensive than their cows’ milk based counterparts. MICRONUTRIENT COMPOSITION

A possible advantage to using FOFM over first infant formula is related to its fortification with iron. Iron-deficiency anaemia is one of the most common nutritional deficiencies in infants and toddlers.8 Babies’ iron stores are much reduced at around six months of age and require iron-containing solids to be introduced in complementary feeding to meet demands for growth.9 A recent study10 found FOFM to be positively associated with iron status in late infancy, whilst cows’ milk was www.NHDmag.com April 2017 - Issue 123

PAEDIATRIC Table 1: A comparison of the most commonly used FOFM to the same brand’s first infant milk in the UK per 100ml of prepared feed (figures based on powder formula) Brand

Energy Protein GOS/ Omega-3 Total (kcal) (g) FOS LCPs CHO (g) (g)

Total sugar (g)

Iron (mg)

Vitamin pence pence D (μg) /100ml /500ml

Cost per mth (500ml/ day)#

8.6

8.5

1.0

1.5

13.5

73.5

£22.05

7.3

0.53

1.2

14.7

67.5

£20.25

7.8

7.6

1.0

1.2

13.7

74.9

£22.47

Cow & Gate FOFM

1.4

0.8

Cow & Gate First

1.3

0.8

HiPP FOFM

1.5

0.5

HiPP First

1.25

0.3

7.0mg DHA

7.3

7.2

0.5

1.2

15.0

68.5

£20.56

SMA Pro FOFM

1.3

0.4

8.8mg DHA

7.9

5.5*

1.0

1.2

17.2

86.2

£25.87

SMA Pro first

1.25

0.4

8.4mg DHA

7.1

0.7

0.9

16.5

82.5

£24.75

Aptamil FOFM

1.4

0.8

1.8mg EPA 8.6mg DHA

8.6

6.5*

1.0

1.4

18.0

89.8

£26.95

Aptamil first

1.3

10mg DHA

7.3

0.53

1.2

16.5

82.5

£24.75

6.0mg DHA

* Sugars mainly from lactose, but includes maltodextrin # Costing derived from Tesco supermarket online website, using powdered formula

negatively associated. Breastfeeding, however, did not impact negatively on iron status. FOFM was also found to be beneficial for improving iron stores of babies and toddlers, but not beneficial for their development or growth.11 Thus the evidence shows extra iron may help stores, but the context for this benefit in infants fed a usual weaning diet alongside formula milk is not clear.12 Equally, there have been concerns about infants having too much iron in their diet given the possible reduced absorption of other essential trace elements.9 EFSA published their scientific opinion on the essential composition of infant and followon formulae and made the following important statement: ‘Nutrients and other substances should be added to formulae for infants only in amounts that serve a nutritional or other benefit. The addition in amounts higher than those serving a benefit, or the inclusion of unnecessary substances in formulae puts a burden on the infant’s metabolism and/or physiological 12

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functions as substances which are not used or stored have to be excreted.’7 It is notable that both the World Health Organisation (WHO) and DH do not recommend FOFM and consider these products to be unnecessary.13 With these clear messages from scientific experts, why is it that large proportions of babies are given FOFM in the UK? BREASTFEEDING

Breastmilk is uniquely tailored to each individual human baby and contains both known and unknown properties which promote survival and development.14 There are more than 100 substances present in breastmilk which are not present in artificial infant milks.14 Despite WHO and DH advice that mothers should breastfeed exclusively to six months of age and continue breastfeeding as long as is desired, UK breastfeeding rates are amongst the lowest in the world, with only 1% of babies being breastfed exclusively to six months15 vs 36% globally.16

The majority of mothers in the UK say that they wanted to breastfeed for longer (90% who stopped by six weeks; 63% of mothers interviewed when their babies were six to eight months old15). So why do mothers stop? It is often reported that mothers “did not have enough milk” or did not receive support when needed.17 Could messages from the media (advertising/social media/ television) be affecting mothers’ choices?13,16-18 Does advertising legitimise the switch from breastfeeding to formula feeding? Also, does advertising to healthcare professionals affect our advice when asked whether to use FOFM? THE INFLUENCE OF MARKETING

Marketing claims for FOFM include the following: “Help support a weaning diet” “Targeted at the specific nutritional needs of babies” “Fortified with iron to help normal cognitive development” “Contains omega-3 and 6 essential fatty acids to support normal development and growth” Advertisements influence social norms - or the shared understanding about expectations of behaviour within a social group - by illustrating that the behaviour is common and accepted in the population.20 Try to remember the last formula advert you watched on television. Do you remember the warm feeling associated with it, the baby girl spinning around becoming a ballerina? These feelings help us to remember formula milk and link it to a baby’s development. The messages help to tell us not just that it’s OK to use formula but that it will improve a baby’s development. No improvements in infant development have been found in researching composition of formula milk in comparison to breastmilk.2,11 Did you recall that the advert was for FOFM and not first milk for infants? The International Code for marketing regulation of infant formula (put in place to promote breastfeeding) by the WHO in 1981,21 bans the advertisement of first infant milk; however, as FOFMs are not considered breastmilk substitutes within the EU, this enables FOFM to be freely advertised.

Research into the effects of advertising on first time mothers found that health claims made by the marketeers were accepted uncritically and understood to pertain not only to FOFM but to first infant formula alike.22 Advertising messages imply that choosing to formula feed is a lifestyle choice rather than a difficult decision with health consequences.19 The media also convey that breastfeeding is difficult and that breastmilk substitutes help to settle fussy babies.23 It has been argued that FOFM was created by formulae manufacturers in order to advertise their products,2 and if so, retail sales figures indicate that these marketing strategies are effective. The retail value of the baby milk industry is growing. Global sales of milk formula (including infant formula and FOFM) have increased 20-fold between 1987 to 2013, and account for two-thirds of all baby food sales internationally.24 Growth continues to be strong in the UK in particular, with figures of 4% equivalent to other middle income countries, and larger than the US and France.24 Regulation and monitoring of law in order to reduce unethical marketing with meaningful penalties to protect breastfeeding, is important. However, despite legislation existing, it is not comprehensive and is poorly enforced in the UK.25,26 UNICEF UK recommended following a report published in 2012 that the UK government fully implement the International Code of Marketing of Breastmilk Substitutes and subsequent resolutions. This would result in the banning of advertising of FOFM.27 NEW LEGISLATION

An Infant Feeding All Party Parliamentary Group has brought a bill which at time of writing of this article was due to go through its second reading in the House of Commons on 24th March 2017.28 The new legislation will: • introduce plain packaging for all formula milks; • establish a body, totally independent of industry, to test all products and verify the claims of manufacturers prior to them being licensed for sale; • ban the use of misleading terms such as ‘follow-on’ or ‘growing-up’ formula milks; www.NHDmag.com April 2017 - Issue 123

PAEDIATRIC • stop companies from circumventing existing laws by introducing a ban on identical packaging for stage two and subsequent products; • prohibit formula companies from advertising in health journals and magazines; • bring forward tougher penalties for companies who flaunt the legislation, including greater financial fines and prison sentences for company CEOs; • ban advertising of formula milks on TV, social media, the internet and through parenting clubs. If this bill is passed in the future, it is clear that consumers will be better protected from unethical marketing. It is also hoped that it will work to increase future breastfeeding rates in the UK,29 although this is not certain.30

IN CONCLUSION

Follow-on formulae are not necessary nor recommended for use in infants. They are targeted at infants between six to 12 months of age and advertising is likely to continue to promote their use for the foreseeable future. As healthcare professionals, it is vital that dietitians understand the potential impacts of indirect advertising and interpret marketeers’ health claims correctly and, as such, do not endorse nor promote these products inadvertently. If parents choose to use these products, careful communication about their dispensability is worth considering. However, where this is not successful in changing parent’s choices, it is the professional’s duty to help to identify the best possible option considering their costs, product similarity and limit protein and sugar content where possible.

References 1 Department of Health (2013). Guidance Notes on the Infant Formula and Follow-on Formula Regulations 2007 (as amended). www.gov.uk/government/uploads/ system/uploads/attachment_data/file/204314/Infant_formula_guidance_2013_-_final_6_March.pdf. Accessed 03/03/17 2 Crawley H and Westland S (2017) for First Steps Nutrition Trust. Infant Milks in the UK: A Practical Guide for Health Professionals. http://firststepsnutrition.org/ newpages/Infants/infant_feeding_infant_milks_UK.html. Accessed 3/3/17 3 Crawley H and Westland S (2016). for First Steps Nutrition Trust. Infant Milk Composition. www.firststepsnutrition.org/pdfs/Infant_milk_composition_February2016.pdf Accessed 3/3/17 4 Koletzko B, Bhutta ZA, Cai W et al (2012). Compositional requirements of follow-up formula for use in infancy: recommendations of an International Expert Group coordinated by the Early Nutrition Academy. Annals of Nutrition and Metabolism, DOI: 10.1159/000345906 5 Koletzko B, Koletzko S, Ruemmele F (2009). Drivers of Innovation in Pediatric Nutrition. Nestlé Nutrition Institute 6 European Food Safety Authority (2014). Scientific opinion on the essential composition of infant and follow-on formulae. EFSA Journal, 12 (7), 3760. Available at www. efsa.europa.eu/en/efsajournal/doc/3760.pdf Accessed 03/03/17 7 European Food Safety Authority (2012). Scientific opinion on the suitability of goat milk protein as a source of protein in infant formulae and in follow-on formulae. Available at: www.efsa.europa.eu/en/efsajournal/pub/2603.htm Accessed 03/03/17 8 Stoltzfus RJ (2003). Iron deficiency: global prevalence and consequences. Food Nutr Bull. 24(4 Suppl):S99 9 SACN (2010). Iron and Health. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/339309/SACN_Iron_and_Health_Report.pdf Accessed 03/03/17 10 Thorisdottir AV, Ramel A, Palsson GI, Tomassson H and Thorsdottir I (2013). Iron status of one-year-olds and association with breast milk, cows’ milk or formula in late infancy. European Journal of Nutrition, 52(6 ) 1661-1668 11 Morley R, Abbott R, Fairweather-Tait S, MacFadyen U, Stephenson T and Lucas A (1999). Iron fortified follow-on formula from nine to 18 months improves iron status but not development or growth: a randomised trial. Archives of disease in childhood, 81(3), pp 247-252 12 Daly A, Macdonald A, Aukett A, Williams J, Wolf A, Davidson J, Booth IW (1996). Prevention on anaemia in inner city toddlers by an iron supplemented cows’ milk formula. Archives of Disease in Childhood 75(1): 9-16 13 World Health Organisation (WHO 2013). Information concerning the use and marketing of follow-up formula. www.who.int/nutrition/topics/WHO_brief_fufandcode_ post_17July.pdf Accessed 03/03/17 14 Ballard O, Morrow AL (2013). Human milk composition: nutrients and bioactive factors. Pediatric Clinics of North America, 60, 49-74 15 McAndrew F, Thompson J, Fellows L, Large A, Speed M and Renfrew MJ for Health and Social Care Information Centre (2012). Infant Feeding Survey 2010. http:// content.digital.nhs.uk/catalogue/PuB08694/Infant-Feeding-Survey-2010-Consolidated-Report.pdf Accessed 3/3/17 16 McFadden A, Mason F, Baker J, Begin F, Dykes F, Grummer-Strawn L, Kenney-Muir N, Whitford H, Zehner E, Renfrew MJ (2016). Spotlight on infant formula: coordinated global action needed. Lancet 387(10017): 413-5 17 Odom E, Li R, Scanlon K, Perrine C and Grummer-Strawn L (2013). Reasons for earlier than desired cessation of breastfeeding. Pediatrics, 18, 2012-1295. Available at: http://pediatrics.aappublications.org. Accessed 4/3/17 18 Stewart-Knox B, Gardiner K and Wright M (2003). What is the problem with breastfeeding? A qualitative analysis of infant feeding perceptions. Journal of Human Nutrition and Dietetics, 16: 265-273. doi:10.1046/j.1365-277X.2003.00446.x 19 Piwoz EG, Huffman SL (2015). The Impact of Marketing of Breast Milk Substitutes on WHO-Recommended Breastfeeding Practices. Food and Nutrition Bulletin 36 (4), pp 373-386 20 Schultz PW, Nolan JM, Cialdini RB, Goldstein NJ and Griskevicius V (2007). The constructive, destructive and reconstructive power of social norms. Psychological science, 18(5), pp 429-434 21 World Health Organisation (WHO 1981). International Code of Marketing of Breast Milk Substitutes. Geneva: Available from: www.who.int/nutrition/publications/ infantfeeding/9241541601/en/. Accessed 3/3/17 22 Berry NJ, Jones S, Iverson D (2010). It’s all formula to me: women’s understanding of toddler milk ads. Breastfeeding Review, 18, 1, 21-30 23 Parry K, Taylor E, Hall-Dardess P, Walker M, Labbok M (2013). Understanding women’s interpretations of infant formula advertising. Birth 2013; 40: 115-24 24 Rollins N, Bhandari N, Hajeebhoy N, Horton S, Lutter C, Martines J et al (2016). Why invest and what it will take to improve breastfeeding practices? Lancet 387: 491-504 25 Save the Children. Breastfeeding: policy matters. Identifying strategies to effectively influence political commitment to breastfeeding: a review of six country case studies. London: Save the Children, 2015 26 World Health Organisation (WHO 2013). Country implementation of the International Code of Marketing of Breast Milk Substitutes: status report 2011. Geneva 27 Renfrew MJ et al, for UNICEF UK (2012). Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. http:// dspace.brunel.ac.uk/bitstream/2438/10266/1/Fulltext.pdf Accessed 3/3/17 28 http://services.parliament.uk/bills/2016-17/feedingproductsforbabiesandchildrenadvertisingandpromotion.html 29 Baby Milk Action Group. www.babymilkaction.org/archives/8042. Accessed 3/3/17 30 Balogun OO, O'Sullivan EJ, McFadden A, Ota E, Gavine A, Garner CD, Renfrew MJ, MacGillivray S. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD001688. DOI: 10.1002/14651858.CD001688.pub3, Issue 11. Art No: CD001688. DOI: 10.1002/14651858.CD001688.pub3

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COMMUNITY

NASOGASTRIC FEEDING OF ADULT PATIENTS IN THE COMMUNITY SETTING Sean White Home Enteral Feed Dietitian, Sheffield Teaching Hospitals NHS Foundation Trust

Anne Mensforth Nutrition & Dietetic Service Manager, Leicestershire Partnership NHS Trust

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

BAPEN’s new NG specialist interest group (SIG) will debate complex issues, advance practice and aims to share policies, protocols and resources. It is hoped that the group will address some of the issues highlighted in this article.

When a patient is unable to meet their nutritional requirements via the oral route, the placement of an enteral feeding tube may be considered. The chosen route of feeding is influenced by number of factors, including the length of time that enteral feeding may be required, patient choice and presence of any contraindications to tube placement. If enteral feeding is likely to be required for less than four weeks, a nasogastric tube (NGT) is usually the tube of choice.1 When enteral feeding is required for longer, a gastrostomy or jejunostomy feeding tube should be considered, to avoid some of the problems associated with nasogastric (NG) feeding that will be discussed in this article. However, some patients may remain on longer-term NG feeding for a number of reasons including: • patient choice; • peri-operative enteral feeding; • contraindications to placing an enterostomy feeding tube; • to meet nutritional requirements while waiting for an elective enterostomy feeding tube to be placed; • the requirement for a period of time on an elemental feed, when unable to take this orally; • unclear evidence base regarding feeding route choice during and following chemoradiation for head and neck cancer.2 A clinically stable patient, with the appropriate training and support, can be transferred to their own home or residential care to continue enteral feeding. Gastrostomy feeding remains the dominant route of enteral feeding in the community setting, with just 17% of adult patients on home enteral feeding (HEF) fed via a NGT and a further 4% fed via a naso-duodenal or naso-jejunal tube.3 The aims of this article are to discuss: • potential problems associated with NG feeding in the community setting and strategies to overcome them;

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• discharge planning for a patient on NG feeding; • the importance of specialist teams supporting patients on home NG feeding. NASOGASTRIC TUBE PLACEMENT

Most NG feeding is currently initiated in hospital, with relatively few adults discharged to the community while continuing NG feeds compared to those on gastrostomy feeding. A range of social, psychological and practical problems exists in the context of HEF,4 but this article will focus on practical issues regarding NG feeding, including the avoidance of tube displacement and requirement to confirm correct NGT position following initial placement and prior to each administration of feed, medication or water.5 The risks associated with NG feeding were identified as far back as 1851, where patients were said to be ‘drowning with chicken broth’, and NG feeding was described as ‘a troublesome task and if confided to ignorant keepers is also a perilous one’.6 This observation could still apply in today’s NHS. The NPSA Patient Safety Alert published in March 2011, highlighted reports of 21 deaths and 79 cases of harm as a result of feeding into NG tubes placed in a patient’s lungs.5 Misplacement of a NGT into the lung became a ‘never event’ in England from 2009.7 All incidents or near misses should be reported and NHS Trusts are expected to have rigorous systems in place to support staff in safe placement of NGTs.8

Table 1: Risk assessment prior to discharge home Risk

Management strategies

Displaced tube

1. Appropriate tube securement method used, e.g. nasal/cheek securement dressings or bridles. 2. Review of any tube displacement history while in hospital. 3. Consider use of mittens (would require reference to, and compliance with local ‘restraint’ policy). 4. Clear care pathway to deal with displaced tubes.

Unable to confirm correct position of tube

1. If possible, identify and resolve issue prior to hospital discharge. 2. Patient given strategies to obtain aspirate and guidance on interpretation of pH of aspirate. 3. Clear care pathway to deal with inability to confirm correct tube position.

Aspiration

1. Alter feeding method or rate of feed delivery to minimise aspiration risk. 2. Position patient at an angle of greater than 30 degrees. 3. Avoid unsupervised and overnight feeding where the patient is unable to discontinue their own feeds in the event of problems.

Ability to feed via NGT at home.

1. Confirm patient or carers competence to perform feeding method and check NGT position prior to discharge home, including problem solving strategies. 2. Appropriate support arranged for patient, e.g. community nurse, HEF team and care agency visits.

Correct gastric positioning of the tube should be confirmed by checking that fluid withdrawn via the tube has a pH of 5.5 or below, and the external length of the NGT should be documented and re-checked before each feed. Radiography is the alternative method if aspiration is unsuccessful. While hospital inpatients may return to the x-ray department if there is uncertainty regarding tube position, frequent referrals from the community for this purpose would be impractical9 and, indeed, the x-ray ‘snapshot’ could not be relied on to provide assurance later on arrival home. DISCHARGE PLANNING

Discharge planning for HEF should commence as early possible, to identify and overcome possible barriers to a seamless and safe transition to the community setting.10 HEF is a recognised cause of stress and anxiety for patients and their families,11 and for patients with NGTs, the tasks are complicated by the additional safety considerations with this method of feeding. NICE quality standard QS24 alludes to the importance of patient/carer competence and confidence in the management of their own enteral nutrition.12 A range of topics must be included in pre-discharge training, including confirming tube position, feed administration methods and troubleshooting related to frequently encountered problems.1 A lower incidence of enteral-feed-related complications and improved

carer knowledge was observed when caregivers received comprehensive training on nasogastric care prior to discharge of a patient from hospital on NG feeding.13 Patients or carers must be informed of the risks associated with not confirming tube position and advised on the actions to take if they experience problems. Any recurring difficulties confirming tube position identified in hospital should be addressed during the pre-discharge training, though pressure to free hospital beds may limit the time available for patients to practise. Nevertheless, discussion regarding potential scenarios and practical solutions increases confidence and empowers the patient to safely selfmanage problems once home. This in turn may reduce reliance on community health services and lower the incidence of readmission to hospital with tube-related problems. However, there remains contention about how to manage patients who are unable to confirm NGT position in the community, with the only risk-free option being admission to hospital for radiological confirmation.14 The discharging clinical team should complete a rigorous risk assessment and ensure care pathways are in place to ensure feeding can be maintained, prior to a patient being transferred to the community setting on NG feeding (Table 1).5 Good working relationships and lines of communication between the hospital and the www.NHDmag.com April 2017 - Issue 123

COMMUNITY HCPs supporting patients at home are essential to facilitate a smooth transition into primary care. On discharge, detailed referrals should be forwarded to the HEF team, district nurse and GP, with arrangements made to ensure that the patient has a supply of all the equipment they require to safely continue NG feeding at home including: • supply of feed, syringes and other ancillaries as required; • spare NGT securement dressings; • adequate supply of pH paper, based on estimated usage; • a spare NGT for use in the event of a displacement or for routine replacement; • written information about the care of the tube, feeding method and complication management; • contact details for supporting health professionals in the community and hospital. NG FEEDING AT HOME

With the right support and systems in place, patients can safely NG feed at home.15 However, lack of immediate access to HCPs with the knowledge and skills to resolve issues in the community, or direct access to radiology, can result in prolonged periods without feed, water or important medications. Rigorous multidisciplinary, cross-healthcare-setting solutions are needed to manage these problems efficiently when they occur, with the least distress to the patient. Complications patients may face, and strategies for their management are discussed below. Problem 1: Unable to obtain a gastric aspirate Potential causes: • A small volume of gastric contents. • The tip of the NGT not sitting in gastric contents. • The exit port of the NGT being too close to the gastric mucosa. • The NGT may have migrated into the duodenum, coiled back up into the oesophagus, or worse-case scenario be in the lungs. Management strategies: 1. Lie patient on left-hand side. This may encourage the tip of the NGT to fall into the natural reservoir of the stomach. 2. Blow a small volume of air via a syringe down the NGT, to push tip away from gastric mucosa. 18

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3. Check the tube remains at the previous external length measurement. If necessary, advance or withdraw the tube slightly, to encourage NGT to fall into the gastric contents. 4. If safe to do so, ask the patient to take oral fluids. 5. Wait and try again later. HEF recommendations: The patient should have clear guidance on what to do in the event of obtaining no gastric aspirate. This will include seeking advice from community HCPs such as the HEF team or district nurses, or contact details for hospitalbased nutrition nurses or dietitians, depending on the structure of local services. If hospital admission is required, care pathways should be designed to allow the patient efficient access to radiology services, to allow feeding to recommence as soon as possible. Problem 2: Aspirate obtained above pH 5.5 Potential causes: • Proton pump inhibitor (PPI) medication, e.g. omeprazole or lansoprazole. • H2-receptor antagonists, e.g. ranitidine. • Antacids, e.g. Gaviscon. • Frequent bolus feeds or continuous pump feeding not allowing gastric aspirate pH to drop. Management strategies: 1. Allow longer breaks between bolus feeds, or between pump feeding sessions, to allow pH to drop below pH 5.5. 2. Seek advice from the prescriber regarding the need for, and the timings of, antacid medications. 3. If safe to do so, offer oral fluid of an acidic nature (e.g. fresh orange or pineapple juice) to reduce the pH of the aspirate. 4. Be aware of other signs of tube migration or displacement, such as external tube measurement, respiratory distress or recent coughing, retching or vomiting. HEF recommendations: A small number of patients will not be able to gain an aspirate of pH 5.5 or below. Having completed further risk assessment and discussion with clinical governance or the medical team, it may be appropriate in this situation, when there is no reason to suspect displacement since initial insertion, to assess tube position through external observation of the tube.5 Patients should always

be clear about the actions to take when they are unable to confirm the position of their NGT. Problem 3: Displacement of NGT Potential causes: • Coughing or vomiting. • Inadvertently or intentionally pulling the tube. Management strategies: Local strategies need to be developed to minimise the risk of displacement and to ensure that a patient is aware of what to do in the event of this occurrence. These may include the following: 1. Ensure that the tube is well secured at the nose or to the cheek. A number of options are available including nasal securement devices or dressings, e.g. opsite, tegaderm, hypafix. 2. If NGT displacement is likely, the insertion of a nasal bridle may be considered as per local policy. 3. Consider how the feeding method may affect risk of displacement. Bolus feeding may present lower risk due to less time attached to a giving set that could increase likelihood of pulling at NGT. 4. Ensure the patient is on appropriate antiemetic treatment to control vomiting. HEF recommendations: The risk of NGT displacement should be considered carefully before discharging a patient home, and plans for replacement agreed. Some patients may wish to remove and replace their own NGT and training for them or their carer should be considered.16 Assuming this can be accomplished safely, it will empower the patient and reduce demands on community health professionals and acute services.17 Alternatively, efforts should be made to increase the availability of competent community health professionals, such as HEF dietitians or nursing staff appropriate to local arrangements. Barriers to achieving and maintaining competence and confidence may include infrequent NGT placements, where patient numbers are low. If acute hospital attendance is necessary, there should ideally be a designated area, such as a medical assessment unit or ambulatory care area, to reduce the burden on emergency departments and improve the experience for patients.18

IMPORTANCE OF HEF TEAM SUPPORT

Being discharged on HEF is a cause of stress and anxiety for patients and their families.11 With the low prevalence of patients on HEF and even fewer on home NG feeding, generalist HCPs such as district nurses and GPs are unlikely to have sufficient exposure to this practice to deal with the problems described in a safe and efficient manner. Centralising the source of expertise within a HEF team can have benefits for patients and HCPs. Having completed competency based training, HEF team members are able to take on the responsibility for tube placements/replacements and problem solving. Nurses, or dietitians with extended roles, are ideally placed to take on these tasks and in some areas where there are competent HCPs, there is a move towards the initial placement of NGTs and commencement of enteral feeding in the community setting. Positive outcomes from specialised HEF teams managing NG feeding may include: • reduced admissions to hospital, and associated cost savings;19 • improved compliance with enteral feed plans and medication regimens due to reduced incidence of problems; • empowerment of patients and community HCPs to manage NGT-related complications, through training and education; • maintenance of a central source of expertise for the local health region; • strengthened bids for additional staff resource to care for this select group of community based patients. CONCLUSION

With an estimated prevalence of malnutrition in adults in England of 5% and 30% of adults on admission to hospital,20 it could be argued that dietitians treating malnourished patients in the community should have available to them a full toolkit of nutrition support interventions, including NG feeding. A more widespread uptake of this practice may result in more timely initiation of the right nutrition support option for the patient. Further research is required to assess the staff resource required to support this novel approach and to investigate the possible economic and health benefits. www.NHDmag.com April 2017 - Issue 123

FROM HOLDING BACK.. . .TO HOLDING JACK

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IT’s BEEN SHOWN TO:

Little wonder it helps so much

55% 92% 67%

Increase calorie intake by 55% IN ADDITION TO NORMAL diet 2 HAVE 92% COMPLIANCE OF THE PRESCRIBED DAILY AMOUNT3 Reduce ‘MUST’ scoreS IN 67% OF PATIENTS*3,4

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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

CLINICAL

ORAL NUTRITIONAL SUPPLEMENTS IN NUTRITION SUPPORT 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 full article references please email info@ networkhealth group.co.uk

Malnutrition, found commonly in association with disease, can affect all age groups. Older people are more at risk, with hospital patients over the age of 65 at particular risk of becoming malnourished. Nutrition support is a necessary part of patient care which can include the use of oral nutritional supplements (ONS). Nutrition support ensures that patients have access to nutritional food to meet their needs either in hospital or in the community. Good nutritional care includes nutritional screening to identify a patient’s risk of malnutrition, care planning to ensure that a patient receives the appropriate nutrition at the right time and monitoring by healthcare professionals with the relevant skills and training in nutritional monitoring. ONS can complement (or possibly even replace), a normal diet to provide patients with the essential nutrients required when food alone is insufficient to meet their daily nutritional needs. GUIDELINES AND RECOMMENDATIONS

In the UK, NICE Quality Statement 241 states, ‘It is important that nutrition support goes beyond just providing sufficient calories and looks to provide all the relevant nutrients that should be contained in a nutritionally complete diet. A management care plan aims to provide this and identifies condition specific circumstances and associated needs linked to nutrition support requirements.’ NICE QS24 recommends that all patients in a care setting should have regular nutritional screening using a validated tool, such as the most commonly used Malnutrition Universal Screening Tool (MUST).2

BAPEN3 recommends that nutritional screening ‘should alert health and social care staff to the need for more detailed nutritional assessment by a dietitian. Decisions about the appropriateness and effectiveness of nutritional support should then be made by the multidisciplinary team.’ NHS England Commissioning Excellent Nutrition and Hydration (2015-2018)4 document recommends the ‘development of service specifications and management structures to ensure high standards of nutrition and hydration care using food and drink, oral nutritional supplements, enteral tube feeding provision or intravenous support as necessary ensuring appropriateness and safe standards of practice in line with NICE Clinical Guidance CG325 and associated QS241 and CG1746.’ INDICATIONS FOR USE

Oral Nutritional Supplements in the form of sterile liquids, semi-solids or powders (see Table 1 overleaf), provide macro and micro nutrients and their use must be approved by the Advisory Committee on Borderline Substances (ACBS). ONS cannot be used as a sole source of nutrition as they are not all nutritionally complete, as they contain varying concentrations of macronutrients and micronutrients. www.NHDmag.com April 2017 - Issue 123

CLINICAL Table 1: Types of ONS available3 Type

Notes

Juice type

Volume ranges from 200-220ml with an energy density of 1.25-1.5kcal/ml. They are fat free

Milkshake type

Volume ranges from 125-220ml, energy density ranges from 1-2.4kcal/ml. Also available with added fibre.

High-energy powders

Volume ranges from ~125-350ml, ideally made up with full cream milk to give an energy density of 1.5-2.5kcal/ml.

Soup type

Volume ranges from 200-330ml. Some are ready mixed and others are a powder and can be made up with water or milk to give an energy density of 1–1.5kcal/ml.

Semi-solid/dysphagia ranges

Range of presentations from thickened liquids (stage 1 and 2) to smooth pudding styles (stage 3), with an energy density of ~1.4-2.5kcal/ml.

High protein

Range of presentations; jellies, shots, milkshake style containing 11-20g of protein in volumes ranging from 30-220ml.

Low volume high concentration (shots)

These are fat and protein based products that are taken in small quantities (shots), typically 30-40ml as a dose taken 3-4 times daily.

Dietitians are essential in making individual dietetic assessments to ensure that ONS prescriptions are appropriately advised. Indications for use of ONS include the following conditions and diseases:3 • Short bowel syndrome • Dysphagia • Intractable malabsorption • Pre-operative preparation of undernourished patients • Inflammatory bowel disease • Total gastrectomy • Bowel fistulae • Disease related malnutrition (chronic/acute) MONITORING

ONS should not be prescribed without being monitored to ensure that they remain appropriate and are being taken as prescribed. The prescription should be reviewed according to the person’s progress, and care should be taken when: • using food fortification which tends to supplement energy and/or protein without adequate micronutrients and minerals; • using feeds and supplements that meet full energy and nitrogen needs, as they may not provide adequate micronutrients 22

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and minerals when only used in a supplementary role. Oral nutrition support should be stopped when the patient is established on adequate oral intake from normal food and dietary intake is meeting nutritional requirements, or when a patient can no longer tolerate them due to taste fatigue. RESPONSIBLE PRESCRIBING

As the financial limitations of the NHS are ever more prominent, it is typical for ONS and other prescribed products such as gluten-free foods to be limited or completely restricted. The rationale for this practice is to ensure valuable resources are not wasted. However, malnutrition affects up to 40% of patients being admitted to hospital.7 This can increase the risk of complications, length of stay by 25-75% and the risk of readmission.7 In the community, malnourished patients may present to the GP 25-35% more than well-nourished patients, with a greater risk of hospital admission.7 In 2015, a systematic review with meta-analysis by Elia et al suggested that there are cost savings and it is cost effective to use ONS in the hospital and community settings when used appropriately.7

CASE STUDY Charlie, a 10-year-old boy, was referred for a dietetic review by his community paediatrician due to concerns regarding his static weight and the limited variety of foods in his diet. Charlie required an operation on his hip; however, the surgical team and paediatrician were concerned that he had not gained weight in the last six months and this would increase the risks of complications post operatively. They had hoped for dietetic intervention to improve his weight before the surgery. The referral stated that he was born at 39 plus four weeks gestation on the 2nd centile with a head circumference on the 9th centile, his length was between the 2nd and 9th centile. 1 Assessment A diagnosis of mild cerebral palsy was given at 12 months of age, as milestones, such as sitting, crawling and babbling, were delayed and inconsistent. He had a developmental delay of around six to eight months. He started walking at the age of two years and required physiotherapy and orthotic input to support the development and stability of his mobility. His speech developed well once he started to attend school full time and there were no concerns here. Cognitively he was now well matched to his peers and he was attending a main stream school. He still required specialist footwear and leg splints to support his mobility. He was generally well. At the initial assessment Charlie’s weight and height had remained static and matched that on the referral. Weight 22kg (0.4th centile), Height 131cm (9th centile) and BMI 12.8kg/m2 (0.4th centile). Mum explained that Charlie had been a ‘poor eater’ since weaning. He didn’t take to mixed textured foods well. He continued with a smooth pureed diet until he was well over 12 months. They saw a dietitian at that time and they were prescribed a 1kcal/ml oral supplement to support his low calorie diet of pureed fruits and yoghurts. He took this well and preferred the strawberry flavour only. When he did progress to more textured foods, he was approximately two years old. He would accept bite and melt textures and fork mashed foods. He disliked any mixed textured foods such as baked beans, spaghetti Bolognese or stew. However, his intake improved enough to discontinue the oral supplement. Mum couldn’t remember a time when she didn’t have concerns about Charlie’s food intake, but she felt he always took fluids well. They had intermittently revisited the 1-1.5kcal/ml oral supplements throughout Charlie’s life, particularly when he had several bouts of tonsillitis between the age of five and seven, where he would stop eating altogether. Currently, she relied heavily on milk and dairy products such as yoghurt, ice cream and soft cheese to maximise his energy intake. He was not at all keen on fruits or vegetables. Mum reported mealtime tensions, as Charlie was reluctant to come to the table to eat. He would avoid sitting at the table and had been known to hide food in the plant pots in the dining room. 2 Identification of and plan nutrition and dietetic diagnosis Table 2 overleaf shows an outline of Charlie’s oral intake of food and fluids. This was not consistent and this would be described as a ‘good day’. Some days his packed lunch would return untouched and half or less of the intake reported at evening meal time would taken. His estimated requirements would be around 1970kcal and 28.3g protein per day.8 He was not meeting his requirements for energy and his intake of many micronutrients as well as fibre was poor. Mum was worried about Charlie’s bowel movements, she explained he was often constipated. The community paediatrician had prescribed Movicol (one to two sachets per day); however, these were taken sporadically as Charlie disliked the taste. In light of Charlie’s energy and micronutrient deficits, we discussed the options for increasing his food and fluid intake and variety. Charlie didn’t feel he could eat or drink more, saying he didn’t want to take more. He didn’t feel hungry and disliked food most of the time. He told me that, ‘food was his enemy’. When I discussed this further with him, he explained that he didn’t enjoy eating and mealtimes spoiled his time for play at home and school. He wanted everyone to stop telling him to eat more. We then discussed using oral nutritional supplements. Charlie spoke about how he felt about taking them, saying he liked oral supplements as long as they were strawberry flavour. We also talked about how and when he would take them. He agreed to have 3 x 125ml, 2.4.kcal plus fibre milkshake style supplement drinks per day, providing 900kcal and 17.1g protein, with much greater support for micronutrient intake. Whilst he would need additional calories to support catch up growth, Mum didn’t feel he would consume these at this time. We planned to review after three months. www.NHDmag.com April 2017 - Issue 123

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Fresenius Kabi Limited, Cestrian Court, Eastgate Way, Manor Park, Runcorn, Cheshire, WA7 1NT Tel: 01928 533516 | Fax: 01928 533520 Email: scientific.affairsUK@fresenius-kabi.com www.fresenius-kabi.co.uk ® Fresubin is a registered trademark of Fresenius Kabi AG. Fresenius Kabi Ltd is an authorised user. © Fresenius Kabi Ltd. July 2016. Date of preparation: July 2016 Job code: EN01293

CLINICAL Table 2: A typical day’s intake for Charlie Estimated calorie intake

Estimated protein intake

Time

Food/drinks taken

Breakfast (7.30-8am)

1-2 full fat soft cheese triangles 100ml full fat milk Mouthful of toast (sometimes nil)

Snack at school (10.15am)

Nil or very occasionally a small banana (100g) 103kcal 150ml full fat milk 96kcal

1.2g 4.8g

Lunch (12.15am)

Packed lunch as won’t take the school meals 2 full fat cheese triangles 1 full fat yoghurt (125g pot) 1-2 cocktail sausage rolls (30g)

70kcal 123kcal 91-182kcal

4.2g 4.3g 2.9-5.8g

Snack after school (4pm)

Full fat yogurt (125g pot) 150ml full fat milk

123kcal 96kcal

4.3g 4.8g

Evening meal (5.30pm)

Various options but generally: 1-2 fish fingers or skinless sausages (grilled) 1 tablespoon of tomato ketchup Offered peas or baked beans - not eaten ½ -1 potato waffle Offered no added sugar squash - may take 100ml at best

App. 110-130kcal 15kcal

5-7g 0.2g

44-88kcal

0.5-1g

Supper (7.30pm)

Offered food such as crumpet or toast - nil taken Occasionally takes another 150ml full fat milk

96kcal

4.8g

Total intake

847-1037kcal

44.3-51.8g

35-70kcal 64kcal

2.1-4.2g 3.2g

Values taken from www.tesco.com/groceries/ <accessed 15/03/17>

3 Monitor and review At his review appointment, Charlie explained that he was enjoying the oral supplements and he had gained a small amount of weight and grown enough to continue along his centiles. Mum had noticed some improvement in his bowel movements. He was opening them every other day since taking the supplements with fibre. He still wouldn’t take the Movicol. Mum updated me with some progress regarding interactions with other health teams. Charlie had been referred to CAMHS for an autism assessment. His school support and teaching staff has expressed some concerns regarding his behaviour and his community paediatric agreed that he was displaying some traits of autism. Mum felt that this explained some of Charlie’s feeding history and current behaviours. As a result, the family had placed less pressure on him to eat and drink more. She felt this was also due to the support from the ONS and the ‘goodness’ they were providing. Overall she felt the nutrition support and CAMHS assessment had helped to improve their relationship and Charlie seemed more relaxed. He was happy to continue to take the 3 x 125ml, 2.4kcal oral supplements; however, he was not willing to increase this volume or take any additional food. We agreed to continue with the current amount and to review again in three months’ time. He would be monitored for weight and height in between dietetic appointments at the next paediatrician appointment, which was a comfort to Mum. 4 Evaluation Charlie continues to take the oral supplements as an ongoing intervention. He has not showed any indication of increasing his food intake, but has agreed to increase the volume of oral supplements to 4 x 125ml per day, which continues to help and support some additional weight gain and growth. www.NHDmag.com April 2017 - Issue 123

1. Data on file. Abbott Laboratories Ltd., 2007 (PaediaSure Plus & PaediaSure Plus Fibre taste testing). 2. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure Fibre taste testing). 3. Data on file. Abbott Laboratories Ltd., 2013 (PaediaSure & PaediaSure Peptide vs. Peptamen Junior Powder). *Independent, head-to-head taste testing for PaediaSure, PaediaSure Plus, PaediaSure Fibre, PaediaSure Plus Fibre, and PaediaSure Peptide vs. Fortini or Frebini Energy or Peptamen Junior Powder Date of preparation: March 2017 ANUKANI170057

OUR NEXT PAEDIATRIC ONS, WILL BE OUR SMALLEST PAEDIATRIC ONS. The PaediaSure range includes some of the best-tasting, most-loved paediatric ONS on the market.1â&#x20AC;&#x201C;3* But sometimes kids need all that nutrition, flavour, and goodness to come in a smaller volume. So our next addition will be our smallest addition, providing everything they love about PaediaSure, in a size they will too.

FOOD & DRINK

JUICES AND SMOOTHIES: WHAT ARE THE CURRENT TRENDS? Priya Tew Freelance Dietitian, Dietitian UK Priya runs Dietitian UK, a freelance dietetic service. She provides 1-2-1 support for clients with eating disorders, IBS and weaning. Dietitian UK works with various companies and brands as well as providing media work.

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

The drinks market is exploding with a plethora of beverages that are marketed as being healthy and able to boost our bodyâ&#x20AC;&#x2122;s functions. This year seems set to bring the most outlandish drinks yet. As nutrition professionals, these are things we need to stay educated on, so here is a summary of some of the latest juicing and plant water trends. Juicing is always going to be second best compared to eating the whole fruit. However, it can be a useful way to encourage people to increase their fruit and vegetable intake and to include a range on micronutrients in their diet. The green smoothie or juice is still in and is positive as it encourages people to eat their greens, reduces the amount of fruit used in juices and increases the nutritional content of their diets. Choosing smoothies over juices will improve the fibre content, or when making juices at home, the pulp from the juice can be added into soups, pasta sauces and stews. With homemade juices or juice bars where there is no pasteurisation, there can be a slight risk of food poisoning. At risk groups are people with a weakened immune system, the elderly, pregnant ladies and infants. Any bacteria on the outside and inside of the fruit, can become part of the finished product. To reduce the risks, all equipment used and the outside of fruit and vegetables need to be washed. Beetroot juice: Becoming more popular is Beetroot juice. Beetroot is a rich source of fibre, folate and manganese, potassium, iron and vitamin C. It also contains thiamine, riboflavin, vitamin B-6, pantothenic acid, choline, betaine, magnesium, phosphorus, zinc, copper and selenium. Watch out as this one will turn urine pink/red. Evidence: Beetroot juice is rich in inorganic nitrates, it has a higher

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antioxidant and polyphenol content compared to other fruit and vegetable juices.1,2 A meta-analysis and review of 16 cross-over trials, with a total of 245 people, found a significant reduction (-4.4mm Hg) in systolic blood pressure with beetroot juice.3 A systematic review of 47 studies found that nitrate supplementation including beetroot juice was associated with a modest improvement in time to exhaustion tests, showing that there could be some benefits for endurance exercise.4 This needs further testing to see how much is needed to elicit the benefits. Charcoal juice: Charcoal juice is as ridiculous as it sounds. Meant to bind with toxins to speed up their elimination from the body and to rehydrate you better than water. Evidence: None. Risks: It can affect the absorption of some medicines and care should be taken for pregnant and breastfeeding women. GUIDELINES ON JUICES AND SMOOTHIES

After the update to the Eatwell Guide, the message on fruit juices is that one 150ml glass of fruit juice can count as a portion, just once a day. This makes perfect sense in terms of the high sugar content and low fibre. Presumably, this will be the same for vegetable juices too. Of interest is the bought smoothie recommendation. Many of these state that they contain

‘The government’s 5-A-Day guidance states that an individual smoothie product can only count as one portion maximum toward your 5-A-Day. This is because the process results in an end product with very little fibre, compared with the raw ingredient.

more than one portion on the bottles; however, the public health message is that we again only count these as one portion a day due to their low fibre content - they are often filtered or sieved to remove ‘the bits’. There is no guidance on how to judge the portions of fruit and vegetables in a homemade smoothie which can be very different. Smoothies made at home can contain nuts, seeds, nut butters, oats as well as fruit and vegetables, so can be higher in fibre, thus altering the effects of the sugar content of the smoothie. Dietitian Rosie Saunt, (See: www.rosie-saunt.com/?p=2083) asked Public Health England to clarify their guidance on smoothies counting towards the 5-A-Day message. The response was as follows: ‘The government’s 5-A-Day guidance states that an individual smoothie product can only count as one portion maximum toward your 5-A-Day. This is because the process results in an end product with very little fibre, compared with the raw ingredient. Part of the reason why fruit and vegetables form such an important part of a person’s diet is their fibre content. Therefore, without receiving enough fibre, you are unable to achieve your 5-A-Day. ‘However, this advice generally covers bought smoothies rather than homemade ones - many

commercial smoothies are filtered or sieved, which means it is common that some of the fibre is removed. Provided that you are using as much of the edible fruit as possible, without sieving, and blending it only as much as is required to make the correct consistency, and consume all the juice and bits, your own homemade smoothies may count as more (depending on how many fruits or vegetables you use and the quantities). ‘Since extraction of juice from fruits or vegetables reduces the fibre content and releases non-milk extrinsic sugars, fruit or vegetable juices are not counted as more than one portion in a day, however much is drunk. Therefore, advice to consumers is that fruit juice should be limited to no more than one 150ml portion a day.’ So, the message is that unsweetened 100% fruit juice, vegetable juice and smoothies can only ever count as a maximum of one portion of your 5-A-Day. If you have two glasses of fruit juice and a smoothie in one day, that still only counts as one portion. Your combined total of drinks from fruit juice, vegetable juice and smoothies should not be more than 150ml a day (i.e. a small glass). For example, if you have 150ml of orange juice and 150ml smoothie in one day, you’ll have exceeded the recommendation by 150ml. www.NHDmag.com April 2017 - Issue 123

FOOD & DRINK PLANT WATERS

Birch water, made by tapping the tree, is usually flavoured and marketed as being a lower sugar alternative to coconut water, however, some versions have added sugar. It contains 7.5kcals per 250ml serving and the nutrients manganese, potassium, zinc and xylitol. Claims are made about it cleansing and detoxifying the body, for which there is no evidence.

Maple water is also made by tapping the tree. Usually this would be boiled down to make maple syrup, so you can imagine it has a sweet taste, containing 3-4g sugar per 250ml serving. Claims are made about it being anti-inflammatory and helping muscle recover, post workout amongst numerous other claims, but these are not backed up with evidence. It does contain plenty of manganese and we know that maple syrup has around 50 phytonutrients and good antioxidant activity, but this watered down will not be in the same league.5 Cactus water has a bold claim of helping with hangovers after a one-off study on 64 adults found that the risk of severe hangover was reduced by 50%, so this could be a popular one.6 Made from prickly pear extract and concentrate, water and flavouring, cactus water contains betalains, antioxidants which have been shown to hinder LDL oxidation when cactus pear fruit pulp was consumed.7 Watermelon water contains beta-carotene and potassium, vitamin C, lycopene and the amino acid L-Citrulline, which is converted to L-arginine in the body. It is used as a sports performance aid and supplementation has been shown to reduce fatigue and improve endurance in exercise.8 In a few small cross-over studies, watermelon extract has been found to reduce systolic aortic blood pressure and could be a helpful aid in hypertension.9,10 Whether this would also be the case for watermelon water is unknown. Aloe Vera water is sweetened with agave, with added flavourings, making a standard serving 60-70kcals. It contains vitamins A, E and 30% of the DRI for vitamin C. There is some limited evidence for Aloe Vera sap, but the watered down version has no real research conducted on it. Artichoke water is said to be high in vitamin A, B and C, magnesium and antioxidants, the top two being cynarin and silymarin. Artichoke water is a yellow-green colour and made by mulching whole artichokes, the stem, leaf and heart. The manufacturers say it can help lower cholesterol and aid with weight loss, but there is no research to support this. Coconut water has been popular in the UK. Used for rehydration purposes in developing countries and as a sports rehydration drink by some due to the level of electrolytes it contains. It also contains B and C vitamins, calcium, magnesium and potassium. It doesnâ&#x20AC;&#x2122;t provide much more benefit to exercisers over water and a banana, but it also wonâ&#x20AC;&#x2122;t do any harm for those who prefer it. 30

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All these drinks come with a hefty price tag, with either extremely limited or no evidence. Some varieties will have added sugar, so are not as virtuous as they first sound.

However, some of these juices and smoothies could make good alternatives to water for people wanting a change or wanting to replace a soft drink.

Table 1: Composition of alternative waters Energy/Kcals

Carbohydrates/g

Sugars/g

Other nutrients

Birch water

3kcals

0.8g

Maple water

10kcals

2.4g

Manganese 0.19mg

Aloe Vera water

39kcals

9.6g

4.6g

Vitamin C 26mg 32% RDI

Watermelon water

40kcals

6.6g

5.3g

Vitamin C 60%, Manganese 8% and Vitamin A 4% of RDI.

Coconut water

19kcals

3.7g

2.6g

Magnesium 6%, Vitamin C 4% and Calcium 2% of RDI.

Almost two-thirds of parents say their children manage a maximum of just three portions of fruit and vegetables a day A new consumer survey of 2,000 parents has revealed that 60% of them say their children only manage three or less of their five-a-day1. A 150ml glass of pure fruit juice is an easy way to get one of your 5-a-day, but the new data found 17% of parents said they never give their children pure fruit juice and a substantial majority (94%) of parents surveyed did not know that a 150ml glass of orange juice contains all your RDA of vitamin C.

of Vitamin C, with more than half of parents questioned (55%) not knowing about any of its benefits2. Health professionals play a crucial role in helping parents aim for the 5-a-day target and use their expertise to clarify confusing nutritional issues. Interested in hearing more about the latest fruit juice research? Get in touch with Kimberly.Haider@porternovelli.co.uk

Indeed, the new data revealed an alarming lack of knowledge about the health benefits 1 2

Survey of 2003 parents carried out by Censuswide and commissioned by the British Fruit Juice Association (March, 2017) That it is important for healing wounds, protection from viral and bacterial infections, immune system support, prevention of scurvy, cell lifespan and lowering cholesterol

www.NHDmag.com April 2017 - Issue 123

The future is here

sphere

™

PKU sphere™ is available in two flavours – Vanilla and Red Berry – and is interchangeable with PKU express®, PKU cooler® and PKU air®. Suitable from 6 years of age. The lowest* calorie GMP based protein substitute available for PKU. The lowest* volume GMP based protein substitute available for PKU. The first GMP based protein substitute to be evaluated long term# in children and teenagers.1 Palatability may improve adherence in patient groups associated with wavering compliance.1

sphe re

20g PE 120

kcals

36mg

Phe

For more information about PKU sphere or to request samples for your patients with PKU, please contact your Vitaflo representative.

PKU (Phenylketonuria). GMP (Glycomacropeptide). PE (protein equivalent). Phe (Phenylalanine). 1 Data on file. *Lowest per 20g PE. #Minimum 6 months in children aged between 6 and 16 years. PKU sphere™ is a food for special medical purposes and must be used under medical supervision. For the dietary management of PKU.

Innovation in Nutrition

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

T 0151 709 9020 E vitaflo@vitaflo.co.uk W www.vitaflo.co.uk

A Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool, L3 4BQ.

NHD0317

Contains allergens: milk, soya, fish.

IMD WATCH

PKU: EUROPEAN GUIDELINES - WHAT DO THEY MEAN FOR ADULTS? Suzanne Ford NSPKU Dietitian for Adults

Dr Anita MacDonald, Consultant Dietitian in IMD

Suzanne Ford works as a Metabolic Dietitian for Adults at North Bristol NHS Trust. She has been a Dietitian for 21 years, with six of them working in Metabolic Disease. Professor Anita MacDonald is Consultant Dietitian at Birmingham Children’s Hospital and has almost 40 years’ experience in Paediatric and IMD dietetics.

Phenylketonuria (PKU) is a rare, inborn error in the metabolism of one of the essential amino acids - phenylalanine (Phe). European Guidelines for the Diagnosis and Management of PKU were published this year and describe best practice for professionals treating both children and adults with PKU. This article will consider the key recommendations and their meaning for adults with PKU, (maternal PKU will be covered in NHD later this year). A total of 69 recommendations for PKU management have been formulated by the European Guidelines team and the 10 key guidelines have now been published. Scottish Intercollegiate Guidelines Network method and Delphi methods were used to assess evidence, grade it and form a consensus for best practice in areas of management with incomplete or equivocal evidence. PKU is caused by a deficiency of the hepatic enzyme phenylalanine 4-hydroxylase (PAH) which converts excess phenylalanine to tyrosine. Classical PKU is characterised by phenylalanine levels >1200umol/L. As well as high levels of phenylalanine, severe PAH deficiency may also result in a low tyrosine levels which is a semiessential amino acid. Untreated, PKU leads to irreversible brain damage; however, individuals with ‘early treated’ PKU (identified via newborn screening) show normal intellectual and motor development. There is evidence to suggest neuropsychological compromises do still occur in people with early treated PKU, which then lead to behavioural and social issues. DIETARY TREATMENT - A RECAP

The only treatment for PKU in the UK is dietary treatment involving the restriction of natural protein in order to limit the amount of dietary phenylalanine. Phenylalanine is an

essential amino acid and a controlled amount is needed to prevent deficiency. 50mg of phenylalanine is termed ‘one exchange’ and is equivalent to 1g natural protein. To achieve new target phenylalanine levels of 120-600µmol/L, an adult with classical PKU might be prescribed between six to 15 exchanges (roughly equivalent to 6-15g protein). The diet is composed of: • free foods - those naturally low in protein, or manufactured to be low in protein (often prescribed low protein foods); • exchange foods - when measured portions provide the natural protein prescription; and • regular protein substitute (usually amino acids which are phenylalanine free) daily in split doses. The diet is highly restrictive - foods to be avoided are very high in protein such as meat, fish, cheese and eggs etc. However, the degree of protein restriction is such that a very wide range of foods is restricted, such as most cereals, bread, pasta, as well as some vegetables - notably white potatoes. Taking protein substitute is essential to provide nutritional deficiencies which themselves could cause reduced brain functioning (and insufficient exogenous amino acids can cause increased endogenous phenylalanine release and thus a loss of metabolic control). www.NHDmag.com April 2017 - Issue 123

IMD WATCH

People with PKU were not always recommended lifelong dietary management due to a lack of consistent evidence. Adults with PKU currently attending metabolic clinics have different self-selected dietary approaches.

MANAGEMENT OF PKU IN ADULTS

People with PKU were not always recommended lifelong dietary manage-ment due to a lack of consistent evidence. Adults with PKU currently attending metabolic clinics have different selfselected dietary approaches: a) On a strictly controlled low phenylalanine diet and daily protein substitute. b) On a diet with no restrictions at all, i.e. ‘off diet’, or a self-imposed lower protein diet similar to a vegetarian diet, with or without protein substitute. NEW EUROPEAN GUIDELINES

‘Diet for Life’ • Patients with untreated phenylalanine levels more than 600umol/L should be treated for life. • In treated patients with PKU aged 12 years or older, the target phenylalanine concentrations should be 120-600umol/L. Diet for life is the recommendation for all individuals with Phe levels >600umol/L and this is based on evidence that shows significant suboptimal neuropsychological outcomes in early treated adults compared with healthy controls. These outcomes include executive function (cognitive processes that affect behaviour), attention deficits, decreased verbal memory and decreased verbal fluency as well as social and emotional difficulties. 34

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The body of evidence is significant and presented in three meta-analyses considered by the guidelines panel, as well as several well-designed studies which are scientifically robust. In some of the studies used, the evidence is slightly weakened by the presence of patients who have not been continuously treated through life, so deficits could be due to historically raised Phe levels; however, the volume of neuropsychology data and imaging studies (showing white matter changes >600umol/L), has led to the guideline of 600umol/L upper Phe level. Evidence from people who have discontinued diet and returned to it, show that upon regaining metabolic control (i.e. reduced blood phenylalanine levels and improved nutritional status), the individuals experienced improvements, or even reversal of neurological symptoms (including vision loss). This group of people also report an improvement in health-related quality of life upon returning to a Phe-controlled diet. Further information is needed about quality of life in continuously treated people with PKU and a validated PKU-specific quality of life questionnaire is now available online, so that this issue can be explored in more detail. Individuals ‘off diet’ • All adults with PKU should have lifelong systematic follow-up in specialised metabolic centres because of specific risks that might occur during adulthood. The evidence base to support diet for life is relatively new and continuing a Phe-restricted diet for life is burdensome. It is essential that

Self-managed blood spots are for blood phenylalanine only and sent by individuals to laboratories directly. Blood spots are processed quickly, allowing prompt and remote dietary adjustments to achieve the desired blood levels of phenylalanine. adults off diet are not lost to follow-up, so a non-judgmental approach in clinic is needed, whilst informing on the benefits of return to diet and annual clinical and nutritional monitoring. MONITORING & ANNUAL NUTRITIONAL REVIEW

Monthly blood spots Self-managed blood spots are for blood phenylalanine only and sent by individuals to laboratories directly. Blood spots are processed quickly, allowing prompt and remote dietary adjustments to achieve the desired blood levels of phenylalanine. Annual nutritional review Nutritional blood monitoring (taken in clinic) includes the full range of plasma amino acids, serum B12, homocysteine or methylmalonic acid, folate, ferritin, and full blood count (showing haemoglobin and mean corpuscular volume). Serum Homocysteine is strongly influenced by diet and raised homocysteine levels are found in people whose folate, B12 or B6 status is suboptimal - measuring homocysteine is recommended as serum B12 levels are not an accurate measure of functional deficiency. Serum methylmalonic acid concentrations are also raised when serum B12 concentrations are low. Diet history: a three-day food record or a 24-hour recall should be done annually as a minimum. The diet assessment should also consider the spread of the exchanges through the day and protein substitute consumption including total daily dose, variation through the week, pattern of consumption through the day (split dosing is

ideal for optimal serum phenylalanine stability through the day). Other aspects of metabolic diet history taking includes use of prescribable low protein foods. Anthropometry: weight, height and BMI need to be measured and recorded. Other micronutrients can be tested bio-chemically if clinically indicated, e.g. zinc, selenium, calcium, vitamin D, as well as hormones such as parathyroid hormone. Clinical reviews, neurocognitive assessments and psychosocial function review The guidelines recommend a yearly clinical neurological examination and a yearly clinical assessment of adaptive issues or functions - this means clinically relevant behavioural problems. Every year as a minimum, a clinic appointment must include an investigation into psychosocial functioning and wellbeing and health-related quality of life. The guidelines recommend formal neurocognitive testing (IQ, perception and executive function - which includes inhibitory control, working memory and cognitive flexibility), at age 18 years old. Not all metabolic services have access to a psychologist to undertake the testing as recommended - the rationale for the recommendation is to have a baseline test at this stage, enabling identification of any deterioration in executive and cognitive performance in adult life. The transition to autonomous selfmanagement of PKU by an individual might be complete by 18 years of age. The guideline authors acknowledge that major life events are occurring at this stage, such as moving out of home and/or starting paid employment. www.NHDmag.com April 2017 - Issue 123

IMD WATCH CASE STUDY Erin: Erin is a Second Year Geography student at University Diet: Eight exchanges, i.e. 8g natural protein/d 50g protein equivalents in amino acids Weight = 52kg Challenges: • Erin moved to university - in her first year with Phe of around 700umol/L once she established herself at university. (Her coursework results were excellent!) • Second year at university - Erin moved house - free prescription set up was difficult. • Erin’s protein substitute ran out - her Phe levels increased to >1800umol/L. • High Phe levels are likely to be reducing her higher executive function - with these skills compromised, it is even more difficult to organise her time so that she can cope with academic deadlines administration to get her free prescription documents (and get her protein substitute and low protein foods prescribed again). Dietetic support includes encouragement and reminders and supplying bridging samples of protein substitute and low protein foods. It is vital to help Erin plan tasks and prioritise getting her free prescription document to regain metabolic control and perform well academically. Table 1: Sample Menu with eight exchanges (Erin’s prescribable food is in italics) Breakfast

30g Branflakes and Apricots with 120ml Koko Coconut milk Cup of coffee with Coconut milk

Three exchanges

Mid-morning

Apple and low protein fruit bar; tea

Free foods

Lunch

Low Protein Rustic Toast with Violife cheese, and Cherry Tomatoes 33g packet of crisps; bunch of grapes Pure Orange Juice

Two exchanges

Mid-afternoon

Low protein chocolate chip cookies, tea

Free foods

Evening meal

Jacket Potato with Low Protein Burger Bites, Salad and Thousand Island Dressing** Fruit in Jelly**

**specific brands only

Evening snack

Low Protein Breakfast Cereal with 120ml Koko Coconut milk

SUMMARY

The European Guidelines will bring a clear framework to people with PKU and those involved with their treatment, with the prospect of much improved outcome in thinking, behaviour, social function and (we propose) quality of life. There will be challenges - historically, guidelines have higher permissible blood phenylalanine levels, so it is possible that adults with PKU may need to reduce natural protein intake to achieve the optimal metabolic control

Three exchanges

and, thus, optimal psychosocial outcomes. All adults should have lifelong follow-up in specialised metabolic centres. Adults who choose not to follow optimal PKU dietary treatment need encouragement to attend for annual nutritional review. Lifelong dietary treatment for all those with PKU means that healthcare professionals need to provide continuous support to individuals in order for them to overcome difficulties in this challenging dietary treatment.

Information sources 1 Van Spronsen et al (2017). Key European guidelines for the diagnosis and management of patients with phenylketonuria; Lancet Diabetes & Endocrinology Available online 10 January 2017 2 NSPKU (2014). Management of PKU: A consensus document for the diagnosis and management of children, adolescents and adults with phenylketonuria, 4th Edn Pub: NSPKU London ISBN 0953 5550 03 3 Medical Research Council Working Party on Phenylketonuria. Recommendations on the dietary management of phenylketonuria. Arch Dis Child, 1993, 68 426-7 4 www.nspku.org

www.NHDmag.com April 2017 - Issue 123

CLINICAL

THE USE OF GLYCOMACROPEPTIDE AS AN ALTERNATIVE PROTEIN SOURCE FOR PKU Paula Hallam Registered Dietitian Paula is a Clinical Dietitian at Great Ormond Street Hospital for Children in the Metabolic Team, working predominantly with children with PKU and their families. She is also a Freelance Paediatric Dietitian, director of ‘Tiny Tots Nutrition Ltd’ and mum to two girls.

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

Over the past decade, there has been a growing interest in the use of glycomacropeptide (GMP) as an alternative protein source for Phenylketonuria (PKU), as it is naturally low in phenylalanine (Phe) and rich in other amino acids that are potentially beneficial.1,2,3 However, amino acid based protein substitutes have been used successfully in the treatment of PKU,4,5 so is there any need to change? A recent survey shows that patients are keen for new treatments to be developed.6 PKU is an inborn error of amino acid (AA) metabolism caused by deficient activity in the phenylalanine hydroxylase enzyme, which is needed to convert the essential AA phenylalanine (Phe) to tyrosine.1,7,8 The resulting elevated plasma Phe concentrations adversely affect the developing central nervous system, which causes profound neurological impairment and mental retardation.1 Lifelong treatment with a low phenylalanine diet results in reversal of this devastating phenotype9,10 and a ‘diet for life’ approach is recommended for all patients with PKU.11 The PKU diet consists of three main parts: 1. Restriction of natural protein to limit the amount of phenylalanine ingested to essential amounts for growth and tissue repair. The amount of natural protein allowed depends on the phenylalanine tolerance of each individual child, which is determined by the residual enzyme activity. 2. Phenylalanine-free protein substitute to provide all other essential and non-essential amino acids, as well as vitamins, minerals and trace elements. 3. Foods naturally low in phenylalanine (mainly fruits and some vegetables) and low protein foods available on prescription, to provide calories and variety in the diet. AMINO ACID BASED PROTEIN SUBSTITUTES

In the UK, it is standard practice for all children with PKU to be prescribed an

amino acid based protein substitute to provide all other essential and nonessential amino acids, apart from phenylalanine.7 These protein substitutes are made from synthetic, individual amino acids and are presented as powders, liquids, pastes/gels or tablets. The specialist metabolic dietitian calculates the amount of a particular protein substitute required by a child, depending on their age, weight, metabolic control and phenylalanine tolerance.7 What is glycomacropeptide (GMP)? GMP is a glycophosphopeptide comprised of 64 amino acids (AA) whose unique AA profile includes an absence of aromatic amino acids phenylalanine, tryptophan and tyrosine and higher concentrations of isoleucine and threonine, than those found in other dietary proteins.2 Commercial GMP occurs as a byproduct of cheese production and contains 2.5-5mg phenylalanine per gram of protein.3,12 If GMP is to be used as a primary source of protein in PKU, it must be supplemented with arginine, leucine, histidine, tryptophan and tyrosine.2,3 Adherence issues with protein substitutes Historically, patient compliance with protein substitutes has been poor, mainly due to palatability issues, often described as having a bitter taste and strong odour.13,14 MacDonald et al15 reported that only 38% of young www.NHDmag.com April 2017 - Issue 123

Several studies have reported low bone mineral density (BMD) in PKU patients, but the aetiology of low BMD in PKU is still unknown. A systematic review of 16 studies on BMD and fractures in PKU reported three studies that found significantly lower spine BMD in PKU patients children took the prescribed amount of protein substitute each day, whilst Schulz et al16 found that 20% of older patients had stopped taking their protein substitutes altogether, but were still following a low protein diet. Protein substitutes are an important part of the treatment for PKU, as it has been shown that lower doses of protein substitute adversely affect blood phenylalanine control in children.14 Therefore, it is essential to find a protein substitute that is acceptable and palatable to children with PKU. GMP and palatability Protein substitutes made from GMP have been reported to be more palatable than amino acid based protein substitutes.1,17 Van Calcar et al1 reported that 10 of 11 subjects (age 11-31 years) thought the GMP products to be superior in sensory qualities to amino acid products, after consuming the GMP products for four days. In a longer study of nine weeks, Zaki et al17 found that all patients (10 children, aged four to 16 years) preferred the diet regime supplemented with GMP to the classical amino acid formula due to better taste and satiety. RENAL FUNCTION IN PKU

In a German study, Hennermann et al18 found impaired renal function in 19% of 67 PKU patients (aged 15 to 43 years) on a lifelong phenylalaninerestricted diet, supplemented with amino acids. They also reported proteinuria in 31%, arterial hypertension in 23% and decreasing GFR with 38

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increasing total protein intake.18 However, this has not been a consistent finding in PKU patients. Two large adult metabolic clinics in the UK have not found any evidence of decreased GFR in PKU patients (personal communication). In an eight-day inpatient metabolic study,1 the AA diet introduced a greater dietary potential renal acid load and reduced bicarbonate levels suggesting adaptations consistent with correcting for a metabolic acidosis, when compared with the GMP diet. It is hypothesised that the reported hypercalciuria18 could adversely affect bone health due to bone buffering of H+ ions, resulting in increased bone resorption.2 This theory has been supported in a study of individuals without PKU19 where the neutralizing of dietary acid load with potassium citrate for 24 months resulted in increased BMD. BONE HEALTH AND PKU

Several studies have reported low bone mineral density (BMD) in PKU patients,20,2 but the aetiology of low BMD in PKU is still unknown. A systematic review (SR) of 16 studies on BMD and fractures in PKU21 reported three studies that found significantly lower spine BMD in PKU patients compared to controls and six studies that found 20% of PKU subjects had a clinical fracture, although only one study included control subjects. Out of 12 studies of 412 PKU patients looking at phenylalanine levels and BMD, nine studies showed no correlation between raised phenylalanine levels and low

CLINICAL BMD.21 This SR included late-treated patients which may have skewed results, as these patients are often less mobile than early-treated patients. Another SR of bone health in PKU22 only included early-treated PKU patients. Their results suggested that patients with PKU have lower BMD than controls, but the clinical relevance of this finding is not certain, as the mean BMD was still within normal ranges as defined by the International Society for Clinical Densitometry. Bone health and GMP Solverson et al23 reported that, regardless of diet type (high-Phe casein, low-Phe AA or low-Phe GMP), whole body BMD was significantly lower in PKU compared with wild type (WT) mice. This suggests that low BMD is an inherent feature in PKU, as opposed to the diet type. However, this study also showed that the AA diet yielded a weaker and more brittle bone when compared to the GMP diet in both WT and PKU mice, illustrating that the GMP diet improved bone status.22,23 It is important to note that these were animal studies and the results cannot necessarily be extrapolated to humans with PKU. GUT HEALTH

GMP may have advantages over free amino acids on gut health, as GMP has been shown to promote the growth of beneficial bacteria in the gut of mice and piglets.22,23 In one study,1 GMP resulted in a higher concentration of total AAs in plasma and a significantly lower blood urea nitrogen, measured 2.5 hours after eating breakfast, when compared to the AA diet. This suggests slower absorption of AAs from the GMP than the AA diet and better protein

retention. Amino acid formulations also have a higher osmolality than those made from whole proteins17 and this could have implications for their tolerance. GMP AND METABOLIC CONTROL

GMP products contain a source of phenylalanine - in the range of 1.5mg per gram of protein equivalent12,26 or 15mg Phe per 10g PE. Amino acid protein substitutes do not contain any phenylalanine and the only source of phenylalanine in the diet is natural protein. Daly et al26 found that metabolic control deteriorated (Phe levels increased and tyrosine levels decreased) when GMP replaced AAs in children with PKU aged six to 16 years for six months. GMP could only partly replace the AA supplements due to its adverse effect on metabolic control.26 When PKU children (four to 16 years) were given their protein substitutes as 50% GMP and 50% AA, Zaki et al showed that ‘adequate’ metabolic control could be achieved.17 Although the definition of ‘adequate’ metabolic control was not clear, as the median Phe level at the start of the study was 521μmol/L (range 232-833μmol/L), which is higher than target Phe levels stated previously of, 240-360μmol/L (under 12 years) and 240-600μmol/L (for over 12 year olds). More recently, Daly et al38 has shown that if GMP and amino acid protein substitutes are titrated carefully, phenylalanine control can be maintained within the target range. OBESITY AND PKU

Many studies have reported increased rates of overweight and obesity27,28 and higher body fat percentages29 in children and adults with PKU

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CLINICAL especially in female patients, when compared with the general population. But this is not a consistent finding, as some studies found that dietary treatment for PKU did not increase the risk of obesity.30 Possible advantages of GMP on satiety in PKU It is known that protein is the most satiating macronutrient and whey protein in particular has been shown to induce satiety to a greater extent compared to other proteins.31 Ghrelin is a hormone that stimulates appetite - levels are raised in the fasted state and suppressed following a meal.31,32 GMP has been found to significantly lower postprandial plasma ghrelin concentrations, which is what you would expect following a meal. However, postprandial ghrelin concentrations after an AA based breakfast, were not different from the fasting levels taken prior to the AA breakfast.31 This study suggests a theoretical advantage of suppressing hunger for longer when PKU patients are fed GMP, when compared to AA diets. However, there was no correlation between postprandial ghrelin concentrations and BMI. There is also no evidence that GMP will improve weight management in PKU in the long term as no long-term studies have been reported. Energy value of protein substitutes GMP products from the USA have a mean energy value of 180kcals (range 107-220kcals) per 10g protein equivalent (PE), not including the recent â&#x20AC;&#x2DC;Liteâ&#x20AC;&#x2122; versions of the GMP products. This is compared with an average of 81kcals (range 44-135kcals) per 10g PE in the amino acid based protein substitutes available in the UK. It could be hypothesised that the higher energy values in the GMP products could contribute to the level of obesity seen in PKU. LARGE NEUTRAL AMINO ACIDS (LNAAS)

Studies have shown that the use of LNAAs could be useful in the management of PKU.35,2 Oral LNAA supplementation has been shown to reduce brain Phe concentrations and improve neuropsychological functioning in adults.34 As LNAAs share a common transporter, they can compete with Phe at the level of the gut and blood brain barrier thereby reducing absorption and entry of Phe into the brain. If the transporter

was saturated with other AAs, then less Phe would enter the brain.33,34 The goal of dietary management of PKU is to lower plasma Phe levels, which in turn lowers brain Phe. It is this lower brain Phe that is thought to prevent the damage to the developing brain.33 GMP is rich in LNAAs isoleucine and threonine; with levels being two to three fold higher than those found in other dietary proteins.35 In a study of PKU mice fed AA diets and GMP diets for 47 days, the PKU mice fed the GMP diet had an 11% decrease in plasma Phe levels and a 20% decrease in brain Phe concentrations, when compared to PKU mice fed an AA diet.35 Threonine, given as a dose of 50mg/kg, has been shown to reduce plasma Phe concentrations in humans with PKU,36 although the mechanism for this is not completely understood. In a study of 11 PKU subjects (adults and children), there was a variable response in plasma phenylalanine concentrations after being on the GMP diet for four days, compared with the AA diet.1 There was a mean change of 57 +52umol/L in Phe concentrations, but this ranged from a decrease of 157umol/L to an increase in 257umol/L Phe. In this study,1 the GMP diet resulted in a mean fasting tyrosine concentration that was below the normal range. In a study of 21 children with PKU (mean age 11 years, range six to 16 years), the addition of LNAAs to a modified GMP protein substitute improved metabolic control - median blood Phe results were unchanged and medium tyrosine results were higher, when compared to results from 12 months prior to the study on an amino acid-based protein substitute.37 SUMMARY

There are documented palatability issues with amino acid protein substitutes in children with PKU and GMP offers an alternative, more palatable protein source. However, GMP contains residual Phe and this has been shown in one study to have a detrimental effect on metabolic control in children with PKU. But this deleterious effect can be attenuated by the addition of LNAAs to GMP products. One study reported impaired renal function in adults with PKU on a lifelong Phe restriction www.NHDmag.com April 2017 - Issue 123

CLINICAL supplemented with amino acid protein substitutes, but this has not been consistently reported in other PKU centres around the world. In an eight-day study, a diet supplemented with GMP was shown to decrease the dietary acid load in PKU patients, but the clinical relevance of this finding is not very clear. It has been hypothesised that hypercalciuria could be contributing to the low BMD seen in PKU due to bone resorption, but other studies have suggested that the low BMD seen in PKU is inherent to the disease itself. GMP may have advantages for gastrointestinal health as it has been shown in animal studies to promote the growth of beneficial bacteria in the gut. GMP is also absorbed at a slower rate than amino acids, which may be beneficial for protein retention and feelings of satiety. GMP has also been shown to lower appetite stimulating hormones, thereby decreasing hunger in PKU patients. This may have implications for improving obesity rates, which are high in PKU patients, particularly in females. Although no association has been

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shown between decreased appetite stimulating hormone levels and BMI. Conversely, GMP products for PKU tend to be high in calories and this could worsen the obesity seen in PKU patients. GMP is very high in the LNAAs isoleucine and threonine, which are known to be beneficial to PKU patients by competing with Phe at the blood brain barrier and thereby decreasing brain Phe levels. Amino acid protein substitutes also contain LNAAs, but not to the level as those present in GMP products. OVERALL CONCLUSION

GMP offers several advantages over AA as an alternative protein source for children with PKU. However, issues around metabolic control due to residual Phe in GMP, need to be resolved. Considering the evidence to date, I suggest that GMP could partly replace traditional AA protein substitutes, without compromising metabolic control, in those children/adults who are struggling with the palatability of their AA protein substitutes.

SPORTS NUTRITION

ATHLETES AND ORAL HEALTH Claire Chaudhry NHS Community Diabetes Dietitian/ Private Sports Dietitian, BCUHB/ Claire Sports Nutrition

Poor oral health, i.e. our teeth and gums, can negatively influence an athlete’s ability to bite, chew and swallow food and thus can lead to pain, swelling and inability to eat properly to meet individual nutritional requirements.

In Claire’s 14 years of experience she has worked in acute and community NHS settings. Claire has taught Nutrition topics at universities and colleges and regularly provides talks to groups; NHS and private. www. dietitianclaire.com.

The research into the oral health of athletes/sports people is limited; nevertheless, studies have consistently reported poor oral health in elite athletes since the first report from University College London during the 1968 Olympic Games.1 At the time of writing, the Rugby Six Nations is in full swing and Wales will play Ireland this weekend. The players strength and ability to sprint for a try when needed throughout the 80 minutes, is amazing. After writing this article I am somewhat curious to know if each player’s oral health is as good as their physical health. Poor oral health can lead to dental caries, acid erosion and in extreme cases loss of teeth. What exactly is poor oral health? And what do we know already about the prevalence amongst athletes? Tooth decay, or dental caries, results from the breakdown, by bacteria on the hard tissue, of the teeth called tooth enamel. This occurs due to food left over in the mouth or sugar left on the tooth surface and can eventually cause holes in the teeth. Acid erosion is the erosion of the tooth’s enamel and also gums. Acidic drinks and foods lower the pH level of the mouth leading to acid erosion of the teeth. Drinks that cause acid erosion include acid-based drinks such as fruit juices and sports drinks. Dental trauma is teeth being removed or knocked out, jaw fracture, damage to

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

Claire would like to thank Elizabeth Gronnow RDN (Registered Dental Nurse) for her contribution on this article.

gums, tongue, lips and frenulum; which is the fold of skin beneath the tongue, or between the top lip and gum. Other oral conditions include: • Gingivitis - an inflammation of the gums usually caused by plaque build-up; • Periodontal disease - inflammation of the tissues that surround and support the teeth; • Mouth ulcers, cold sores, swollen tongue; • Burnt mouth through hot or cold food/drink The most recent studies look at oral health in elite/professional athletes: London 2012 and Rio 2016. London 2012 had data from 278 elite/professional athletes from the continents of Africa, America and Europe; and included data from 25 different sports. The results showed high levels of poor oral health including dental caries in 55% of athletes, acid erosion in 45% of athletes, gingivitis in 76% of athletes and periodontal disease in 15% of athletes. They also found that more than 40% of athletes were ‘bothered’ by their oral health and 18% reported a negative impact on their training and performance. Nearly half of the athletes had not undergone a dental examination or hygiene check in the previous year.2 Out of 116 Olympic and Paralympic Dutch athletes participating in Rio 2016, www.NHDmag.com April 2017 - Issue 123

SPORTS NUTRITION a dental screen prior to Rio found that 43% of them needed a direct referral to a general dentist due to poor oral health.3 WHY ARE ATHLETES AT RISK OF POOR ORAL HEALTH?

There are many factors which contribute in the development of poor oral health of athletes including nutrition, dehydration, exercise-induced immune suppression, lack of awareness among athletes, negative health behaviours and a lack of prioritisation in relation to their training schedule. Nutrition and frequency of nutrition, in particular carbohydrates Carbohydrates, like glucose and fructose, in foods, are mouth bacteria’s first food source and, therefore, a diet high in these increases the risk of dental caries. Although every individual is different, in Sports Nutrition, up to 70% of an athlete’s overall diet is likely to come from carbohydrates.4 Due to the energy demands of athletes, they are more likely to consume a high amount of carbohydrates throughout their day; during training and whilst competing. The athlete must also consume a greater amount of carbohydrate intake and fluid intake with greater frequency, i.e. glucose and fructose in foods and or gels and/or isotonic drinks. For both dental caries and acid erosion to occur, it is the frequency rather than the total intake of sugar and acidic foods and fluids that is the contributing factor, thus putting the athlete at greater risk of poor oral health. Dry mouth and imbalance of pH in the mouth from exercising regularly During exercise, our heart rate increases resulting in an increased rate of breathing, which again increases as the intensity of the exercise increases. With increased breathing through the mouth, the mouth becomes drier; when the mouth is dry less saliva is produced. Our saliva helps to neutralise the harmful bacteria in our mouth and also maintains a normal pH balance; therefore, having a dry mouth can lead to dental caries. Dehydration during exercise also causes a dry mouth as well as fatigue and reduced energy levels. Regular swimming in incorrectly chlorinated pools can also lower the pH balance in a swimmer’s mouth, leading to less saliva being produced. 44

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The risk of sports-related oral injuries causing dental trauma All sports have some risk for dental injury, but ‘contact sports’ incur more risk. Contact sports like boxing, rugby, hockey, football and martial arts all carry an increased risk of dental trauma, i.e. teeth removal, gum damage, split lips, split frenulum, bitten tongues and fractured jaws. A study of insurance claims for sports-related dental trauma showed that rugby was the contact sport most responsible, which ranged from 22%-33% of claims.5 HOW CAN ATHLETES IMPROVE THEIR ORAL HEALTH?

Frequency and amount of sugars in the diet are undoubtedly the most important dietary factors in the development of dental caries and poor oral health.6 There is much debate about the burden of dental caries throughout the world and studies highlight the need for a very low sugar intake throughout our lives, with some dental experts suggesting that only 2-3% of our daily energy intake should come from free sugars.7 The majority of dental experts would discourage the frequent use of high fructose and glucose foods and drinks. Current SACN recommendations for free sugar consumption in the UK state that we should be eating no more than 5% of our total daily energy intake.8 According to the most recent National Dietary survey, as a population we are consuming double this daily amount across the age ranges.9 However, to reduce the glucose and fructose intake, as well as frequency in an athlete, will greatly affect their training schedule, stamina, performance and ability to recover. Whatever sport your athlete participates in; whether they are a professional/elite athlete, or an athlete who enjoys keeping fit as a hobby, a dietitian can provide individual dietary advice and education to help achieve optimal oral health, which is an important factor in maintaining good general health and wellbeing. IMPROVING POOR ORAL HEALTH

Running, cycling, gym sessions, gymnastics, dancing, walking etc Educate the athlete to know what fluids they require and when during their exercise schedule.

Table 1: Practical tips for maintaining good oral health aimed at athletes Brushing

Ensure that teeth are brushed twice a day with a soft toothbrush; this can help to minimise gums receding. Avoid brushing teeth straight after an acidic food or fluid, wait about 30 minutes.

Fluoride toothpaste

Use an appropriate fluoride containing toothpaste. Adults and children over the age of six years require 1450ppm fluoride in toothpaste. Always ensure the toothpaste contains no sugar or ingredients ending in ‘ose’, yes surprisingly they do exist!

Xylitol

Use xylitol containing products such as chewing gum between training schedules and after meals and snacks.

Flossing

Floss the teeth once a day as flossing teeth gets in between the hard-to-reach areas in the mouth and helps with gum health. There are huge ranges of floss products available. It is advisable to try a few different ones to see which one suits an individual’s mouth structure best.

Mouthwash

Use alcohol-free mouthwash up to twice a day. Mouthwashes are not to be used straight after brushing but in between brushing teeth throughout the day.

Dental checkups

Have regular dental checkups every six to 12 months with a dentist or hygienist. Ask them to check teeth brushing technique. Concerns regarding oral health in relation to a particular training, nutrition and hydration regime should be discussed with the dentist.

Ensure athletes are always kept well hydrated throughout their training. Keeping well hydrated helps to avoid a dry mouth and thus avoids reduced salivary flow. For most sporting activities under 45 minutes, plain water is adequate to prevent dehydration. If sports drinks or isotonic liquids are used, aim to reduce contact with the teeth by using the following strategies: • Avoid swishing/rinsing the drink around your mouth. • Avoid holding the drink in the mouth. • Use a squeegee bottle to help minimise contact with teeth by directing fluids to the back of mouth. If the athlete uses jelly sweets, gels or isotonic drinks, or any other foods high in carbohydrate, advise them to always carry water with them and if possible that they rinse their mouth out with water after eating or drinking. Scuba diving, swimming (synchronised/lengths) If swimming in chlorinated pools check that the pool’s pH is tested regularly and that the chlorination is correct. Advise the athlete to try not to open the mouth too much underwater and advise against swishing the pool water around the mouth. If a regular scuba diver, either in the

pool or in the sea, ensure the mouthpiece fits correctly to avoid rubbing. Contact sports: rugby, boxing, martial arts Contact sport participants must always use a mouth guard and ensure the guard fits correctly. The benefits of preventing dental trauma in contact sports with a mouth guard are well documented.10 In certain boxing and Taekwondo associations, as well as a mouth guard, head gear which protects the jaw area, must also be worn when sparring.11 CONCLUSION

Regular dental screening must be incorporated into the general preventive healthcare of all professional/elite athletes. Due to the increased risk of poor oral health amongst athletes, it is necessary that any educator coming into contact with athletes (i.e. coaches, dietitians, personal trainers, physiotherapists and sports nutritionists), should ideally also be offering advice on preventing poor oral health as part of their education on maintaining optimal health. As for my rugby team, Pob lwc Cymru, cadwch ar brwsio dannedd! - Good luck Wales, keep on brushing those teeth! www.NHDmag.com April 2017 - Issue 123

PAEDIATRIC BOOK REVIEW

CARING ABOUT HUNGER Review by Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. Shas been a columnist on nutrition for more than 30 years.

AUTHOR: GEORGE KENT PUBLISHER: IRENE PUBLISHING, 2016 ISBN 978-91-88061-15-7 PRICE: Paperback £36.00

“There is no technical obstacle to ending hunger. What is lacking is care,” says Professor George Kent, from the University of Hawai’i. Who could disagree with this common sense statement of the obvious? George Kent’s book shows the thousand ways we attempt to address the technical issues of world food shortage, but we actually close our eyes and shrug our shoulders to the real barriers of getting better food to the hungriest. About one billion people do not have access to enough food calories and George Kent describes this as the hunger holocaust. So many very hungry people would appear to be a natural pull factor for food markets, but tragically and obviously, food distribution systems follow the money, not the need. George even suggests that hungry populations may be of benefit to modern production systems. Something also described in 1786 by Joseph Townsend, “ . . . hunger is not only a peaceable, silent, unremitted pressure, but as the most natural motive to industry and labour, it calls forth the most powerful exertions . . .” FOOD PRODUCTION ISSUES

Food production appears skewed, with the wrong food produced in the wrong places by the wrong means and going to the wrong people. The distance between producers and consumers has grown longer, and the ‘value chain’ has inserted processers and marketeers into the very lucrative middle space, so that farmers and primary producers earn relatively less than ever before. Attempts to ramp up yields has produced astonishing outputs, but George Kent states diminishing improvements, 46

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and that ‘productionist’ policies tend to favour larger richer producers over smaller and more traditional food production systems. He specifically critiques genetic modification (GM) technologies as presenting solutions-without-problems. Cost benefits flow towards corporations rather than growers, and few of the claimed benefits appear to translate into real-world advantages over traditional technologies. Certainly the claimed motivations of feeding hungry populations ring hollow without logistic systems to support distribution, and systems to optimise nutrition rather than cash value. With a presentation of such bleakness and blackness, what can be done? Professor Kent gives detailed and useful descriptions about the many international government and NGO food agencies that attempt to alleviate hunger crises. However, he does not seem enthused or impressed with these mega programmes. Outside corrections are always modelled on top-down rather than bottom-up strategies, and welfare systems outside of food market systems seem developed to silence rather than to help the very poorest. False incentives skew food systems (not in favour of the poor), promote dependency and risk corruption. We are all tired and jaded of aspirational goals and targets announced, without the funding and monitoring needed to deliver these. The reason is, we, all of us, don’t really care.

HUNGER VIOLATES HUMAN RIGHTS

George is a passionate advocate of the concept that adequate food is a human right. Hunger violates human rights. Rights means an obligation to deliver. But this is where globally agreed statements appear pallid and pale; specifically article 28 of the Universal Declaration of Human Rights, and article 55 of the United Nations Charter quoted by George to support the concept, say nothing about food or hunger. Further, implementation to ensure dignity, is a nebulous shadow of a concept. India is perhaps the country that has most robustly applied food rights-based concepts, but implementation in rural areas is much critiqued, and perverse incentives inhibit aspirational changes in the poorest (to retain access to aid and subsidies). The language of ‘rights’ does not (it seems to me) help channel changes, whereas George Kent shows and pleads that systems to heighten caring may do. India demonstrates great food delivery concepts in the ‘caring’ state of Kerala, which has pioneered community food welfare systems. This book is longer and heavier on depressing evidence of continuing world hunger, and our many inept and often symbolic attempts to remedy these challenges. This book is shorter and lighter on what-to-do to address these predictable crises, and advocating caring more, seems frail. We all care about our own babies, but how can that driver of responsibility and action be extended to caring about unknown babies in faraway lands? But big problems with difficult solutions should be a much more important focus of our time and energy, than little problems with easy solutions. So dietitians, get stuck-in to joining others in addressing this issue. No other profession can more claim, ‘caring about hunger’ as its leitmotiv, and so many of the issues that George Kent describes are natural themes for dietitians to address. This book is an excellent introduction and review of the paradox of daily crisis of hunger of others, within our own environment of excess. Hopefully, a few special dietitians will lead future programmes, to address the more political and conceptual issues of caring about the very hungry. Step One: join the World Public Health Nutrition Association (www.wphna.org).

NETWORK HEALTH DIGEST

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View it online at www.NHDmag.com

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ONLINE RESOURCES

WEB WATCH Useful information, research and updates. Visit www.NHDmag.com for full listings. ROYAL COLLEGE OF PAEDIATRICS AND CHILD HEALTH

NHS CHOICES

QUALITY STANDARDS FOR SPECIALIST PAEDIATRIC GASTROENTEROLOGY, HEPATOLOGY AND NUTRITION The RCPCH has partnered with the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) to develop new standards for paediatric gastroenterology, hepatology and nutrition. The purpose of the Quality Standards is to reduce variation in care, ensuring equitable services are available for all infants, children and young people and to improve the health outcomes and quality of life for children with gastroenterology, liver or intestinal disorders throughout the UK. The standards will be formally launched at RCPCH Conference during the BSPGHAN symposium on Wednesday 24 May 2017 from 2-5:45pm.

BEHIND THE HEADLINES "Children who are allowed more than three hours of screen time a day are at greater risk of developing diabetes," The Guardian reports (14/03/17). "Eating a Mediterranean diet cuts deadly breast cancer risk by 40%' in postmenopausal women," says The Mail Online of a widely reported study carried out by researchers in the Netherlands (07/03/17). NHS Choices - Behind the Headlines discusses the news story and the research behind them. The feature looks at the research papers from which the stories sprung, provides evaluation of the studies, the methods used, the results and what they mean. Find more information at www.nhs.uk/News/ Pages/NewsIndex.aspx.

COCHRANE REVIEWS FORMULAS CONTAINING HYDROLYSED PROTEIN FOR PREVENTION OF ALLERGY AND FOOD ALLERGY IN INFANTS (2017) Authors: Osborn DA, Sinn JKH, Jones LJ Published on 15th March 2017, this review asks, ‘Does feeding infants with a formula containing hydrolysed protein result in decreased risk of developing allergy such as asthma, dermatitis/eczema, hay fever and food allergy during infancy and childhood?’ Authors' conclusions: ‘We found no evidence to support short-term or prolonged feeding with a hydrolysed formula compared with exclusive breastfeeding for prevention of allergy. Very low-quality evidence indicates that short-term use of an EHF compared with a CMF may prevent infant CMA. In infants at high risk of allergy not exclusively breastfed, very low-quality evidence suggests that prolonged hydrolysed formula feeding compared with CMF feeding reduces infant allergy and infant CMA. Studies have found no difference in childhood allergy and no difference in specific allergy, including infant and childhood asthma, eczema and rhinitis and infant food allergy. Very low-quality evidence shows that prolonged use of a partially hydrolysed formula compared with a CMF for partial or exclusive feeding was associated with a reduction in infant allergy incidence and CMA incidence, and that prolonged use of an EHF versus a PHF reduces infant food allergy.’ Read more at www.cochrane.org/CD003664/NEONATAL_formulas-containing-hydrolysed-proteinprevention-allergy-and-food-allergy-infants and find the full review at http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD003664.pub4/abstract

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PUBLIC HEALTH ENGLAND NEW REPORT - WEIGHT CHANGE IN PRIMARY SCHOOL AGE CHILDREN ‘Changes in the weight status of children between the first and final years of primary school’ is an analysis of data from the National Child Measurement Programme (NCMP) in four local authorities from 2006 to 2015. Published on 14th March 2017, this report examines how weight status tracks in individual children during primary school using the NCMP data from four local authorities. The participating authorities had a larger than the national average proportion of children from deprived and Black and Asian ethnic communities. The data is, therefore, not nationally representative. To date, analysis of NCMP data has shown that the prevalence of obesity doubles between Reception and Year 6, and is higher in children from certain black and minority ethnic groups and those from the most deprived areas. Available to download as a PDF from www.gov.uk/government/publications/ weight-change-in-primary-school-agechildren.

NEW REPORT - EVERYBODY ACTIVE, EVERY DAY: TWO-YEAR UPDATE This 36-page report is an update on the national physical activity framework for England, which was initially launched in October 2014 and set out the need for action across four domains. Published on 17th March 2017, this update covers the progress of the framework’s four action points: • Active society: creating a social movement • Moving professionals: activating networks of expertise • Active environments: creating the right spaces • Moving at scale: scaling up interventions

that make us active It was thought that negligible changes will have occurred; however, ‘it is positive that between 2013 and 2015-17 there has been a statistically significant 1% increase in the proportion of the population across local areas achieving the recommended 150 minutes of moderate intensity physical activity each week.’ Physical on an individual level has seen improvement also. The full report can be downloaded from www.gov.uk/government/publications/ everybody-active-every-day-2-year-update.

NICE GUIDELINES HEALTHY WORKPLACES: IMPROVING EMPLOYEE MENTAL AND PHYSICAL HEALTH AND WELLBEING: QUALITY STANDARD (QS147) Published March 2017 This Quality Standard covers the health and wellbeing of all employees, including their mental health. It describes high-quality care in priority areas for improvement. It does not cover managing long-term sickness absence. It focuses on contributing to improving outcomes regarding wellbeing of employees, employee satisfaction and sickness absence rates. It also covers the role of line managers and the identification and management of stress. For full details visit www.nice.org.uk/guidance/qs147.

HEAD AND NECK CANCER: QUALITY STANDARD (QS146) Published March 2017 This Quality Standard covers assessing, diagnosing and managing head and neck cancer, including cancer of the upper aero-digestive tract, in young people (aged 16 and 17) and adults (aged 18 and over). It describes high-quality care in priority areas for improvement. Nutritional status is discussed including the need for a prophylactic tube, assessed at diagnosis. Full details can be found at www.nice.org.uk/ guidance/qs146. www.NHDmag.com April 2017 - Issue 123

DATES FOR YOUR DIARY UNIVERSITY OF NOTTINGHAM SCHOOL OF BIOSCIENCES Modules for Dietitians and other Healthcare Professionals

THE ROYAL MARSDEN CONFERENCE CENTRE An Introduction to Nutrition and Cancer in Practice

• Nutrition Support (D24BD2) 19/20th April and 26/27th April

Wednesday 17th May 2017 OR Thursday 7th December 2017

• Paediatric Nutrition (D24PAN) 4th/5th May 2017

Cost: £120

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’.

Don't miss this April . . .

Recipe Analysis: Maximising Accuracy 21st & 25th April One-day course at Kings College London. BDA CPD endorsed www.susanchurchnutrition.co.uk/ recipe-analysis-training/ Tel: 07719 381949

A day for dietitians, nurses and other healthcare professionals who are relatively new to the field of oncology or work in oncology as part of a mixed caseload. The day aims to consider the theory and practical nutritional management of patients with cancer. Teaching will place an emphasis on case study presentations to illustrate the principals involved and provide interactive learning opportunities. Book at www.royalmarsden.nhs.uk/nutrition. Email: conferenceream@rmh.nhs.uk. Tel: 020 7808 2921.

MATTHEW’S FRIENDS KETOCOLLEGE 27th, 28th & 29th June 2017

Allergy Awareness Week 24th-30th April www.allergyuk.org/awareness

Suitable for those new to Ketogenic therapy or wanting to update and network with other Keto teams.

Implementing policy on sugar reduction reformulation, consumer choices and regulation 27th April - Westminster Food and Nutrition, London CPD certified www.westminsterforumprojects.co.uk/conference/ sugar-content-2017/21455

Attend one, two, or three days. Day 1, new for 2017, Medical Masterclass. Approved for CPD by the BDA. Programme and booking at: www.mfclinics.com/keto-college Enquiries to ketocollege@mfclinics.com

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

DIETITIAN - NORTH OF ENGLAND - WATERFALL CATERING GROUP - £30-35K Waterfall Catering Group is a contract catering subsidiary of Elior UK specialising in food services to the Care and Education markets through its brands Caterplus and Taylor Shaw. We are seeking a full-time Dietitian to support our rapidly expanding education business Taylor Shaw. You will be based in the North of England providing support to our Northern Education business. You will part of a small dynamic nutrition team and will also work directly with our operating business team to ensure the delivery of comprehensive nutrition and

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dietetic services. The position provides an excellent opportunity for you to work within industry where your nutrition and dietetic expertise is crucial for the successful delivery of the wider foodservice business and the nutrition services. The role will involve planning and administering nutrition and dietetic activities, using your technical skill set and working with wider teams to ensure evidence-based practise runs in conjunction with the best commercial outcomes. To apply please send CV and covering letter to rosanna@ gartonhardy.com. Closing date: 21st April 2017. More information at: www.dieteticJOBS.co.uk

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.

WANTED . . . a celebrity Registered Dietitian to justify and expand the role of the profession in the provision of simple nutritional advice and support to the public on long-term issues, including weight management. In the past, there have been a few dietitians who it could be said have become well known to their colleagues and the public as a result of appearances in the media. This will not have been an easy path and it is a credit to them that they have made the profession more recognisable and, as such, have given much needed credibility to us all. This ‘call to arms’ if you wish, has been prompted by a ‘fitness goddess’ of long standing, namely 77 year old Diana Moran, aka the Green Goddess of the 1980s, who is showing us, even today, how to engage the public in simple activity without the necessity of weird and wonderful equipment and expensive gym membership. I was fortunate enough to meet her in her green leotard days, whilst at a Hospital Caterers Association (HCA) annual conference and I only wish that we could have combined her approach then with that of a celebrity dietetic colleague. My frustration lies with the fact that we do not seem as a profession to want to breed this outgoing, effervescent, engaging, presentable, professional dietitian and instead we have to leave it to the likes of Gwyneth (detox/goat milk) Paltrow, the Hemsley (clean eating, evangelist) sisters, nutritional therapist Amelia Freer and the like, to have a virtual monopoly on all things diet related, which for most individuals are at best completely impractical and at worst dangerous, not to mention rubbish.

That brings me back sadly to our own professional organisation. I was very disappointed to hear that the Chair Elect of the BDA, Anne Holdoway, took the decision to resign from this position in January. Anne stated, “This has been an extremely hard decision to take and not something I would ever have anticipated when I stood for Chair. This decision has been reached over the seven months as Chair Elect, over which time I have gained a better understanding of the role and the environment within which I am able to operate.” The campaign that Anne had targeted, was to raise the profile of dietitians, indicated to be the number one ask by the membership. On this mandate she was elected. She felt that such a campaign was timely in light of the current financial climate and the lack of understanding by GPs, commissioners, HCPs and the public in general of what dietitians offer. I would agree. It is not something that this writer wishes to discuss further in this column, but it should be a concern to all Registered Dietitians in whatever field they work, that this problem of ‘a recognised identity and worth’ seems to be growing and we do not appear to have a champion to emphasise and demonstrate the potential clinical and financial impact of employing dietitians, let alone to extol the virtues of our profession to the general public. Have your say today. www.NHDmag.com April 2017 - Issue 123

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E XTRA

ADDITIONAL ARTICLES FOR SUBSCRIBERS ONLY

NHDmag.com

April 2017: Issue 123

CPD: Improving perspectives on learning and development

NHD-EXTRA: SKILLS & LEARNING

CPD: IMPROVING PERSPECTIVES ON LEARNING AND DEVELOPMENT 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.

There is huge recognition for learning and development (L&D) in the workplace, whether you work in the public or private sector. The Chartered Institute of Personnel and Development (CIPD) conduct a survey every year to highlight areas for improvement and key trends in L&D. In 2015, it found eLearning methods were increasingly used and commonly found in larger organisations. Up to three quarters of workplaces offer coaching and mentoring, which is set to increase further. In-house or on-the-job training programmes and coaching by line managers or peers remain the most popular development methods.1 Table 1 shows the most common L&D methods. It is expected that an increase in the use of mobile device-based learning, virtual classrooms and webinars will be observed in the coming years. Whilst all of these L&D methods can enrich our professional development, it is acknowledged that there are challenges when reviewing and evaluating the outcomes of these opportunities. Despite the various challenges L&D throws at us, it is an ever-changing landscape and looking back on my experiences of L&D, that this quite apparent. Over the years, as a student and a healthcare professional, you’ll attend many courses and study days, some clinical or others for personal or team-based L&D. Some will bring about those ‘lightbulb’

moments, where everything just makes sense and you’ll leave feeling inspired or empowered. Others will leave your head spinning, or you’ll simply think it didn’t really meet your needs. And there are, of course, the limitations in financial or time resources to attend L&D opportunities. I recently attended a personal development course and whilst keeping an open mind about this opportunity, there’s always a little nag at the back of my brain saying, “you’ve got so much to do; this is using valuable time that could be spent doing your work!” However, as well as learning a new perspective on personal development, I also learnt that spending some time on personal development can reap benefits for the long term. THE 7 HABITS OF HIGHLY EFFECTIVE PEOPLE: PERSPECTIVE THAT INSPIRES IMPROVEMENT©

This course is a well-established approach to being effective in attaining goals. Devised by Franklin Covey,2 the course has work sessions based on the content from The 7 Habits of Highly Effective People by Stephen Covey.3

Table 1: The top five most popular L&D methods1* Method

Percentage use

On-the-job training

50%

Online learning

29%

In-house development programmes

25%

Learning from peers (through face-to-face interactions or online networks)

25%

external conferences, workshops and events

15%

*Based on responses by 1,993 participants. www.NHDmag.com April - Issue 123

SKILLS & LEARNING Figure 1: The basic concept of Honey and Mumford’s Learning Styles.

Source: www.rphrm.curtin.edu.au/2000/issue2/outcomes.html (accessed 23/02/17)

Initially, I thought this would be similar to other personal development exercises I’d been exposed to since being a BSc Dietetics student. However, I was surprised at the deeper level it reached. For example, I know about my learning style, I’m a Pragmatist/Reflector (based on Honey and Mumford’s Learning Styles Questionnaire4, see Figure 1). I prefer to watch and do things as a way of learning. For a rough idea of your learning style visit www.brainboxx.co.uk/A2_LEARNSTYLES/ pages/roughandready.htm (accessed 23/02/17). There is always the VAK learning style to refer to too, which uses our three main sensory receivers: Visual, Auditory and Kinesthetic (movement) to determine our dominant learning style. You may know it as VAKT (Visual, Auditory, Kinesthetic and Tactile). We learn by using all three senses to receive and learn new information and experiences. The 54

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VAK, or VAKT, theory suggests that one or two of these receiving styles is normally dominant, which defines the best way to learn for the individual. The dominate sense may alter depending on the task in question. For more information about VAK or VAKT visit www.nwlink.com/~donclark/hrd/ styles/vakt.html (accessed 23/02/17). When I was at university studying my BSc Dietetics over 12 years ago, the idea of learning styles was first presented to me. It was the first time I’d completed an assessment of this kind. In preparation for placement, my cohort were given a learning styles questionnaire to complete and the outcomes were then discussed as a group. It was an insightful exercise where the penny dropped as to why I preferred to work in a certain way and perhaps why I struggled to work well with some of my fellow students in comparison to others.

THE BENEFIT OF COMPLETING THIS TYPE OF ASSESSMENT

It highlighted my learning strengths and areas for improvement and was presented to my placement co-ordinators where I’d be completing my placements. It was referred to at times throughout my placements in order to provide the correct opportunities to meet my learning preferences, where appropriate. After university its relevance remained part of my own learning journey and the experiences I sought to enhance my development as a clinician. In more recent times, I’ve come to know my ‘Insights Discovery** colours and personality type’; and how these impact on my learning, working and communication styles. After completing a questionnaire, this resource produces a 20-page personality profile, detailing strengths and areas for improvement, as well as giving you your ‘colours’, which describe your energy or traits and a ‘personality type’, which defines your preferred role or position. My energies are predominately sunshine yellow with supporting earth green, very little fiery red and a bit of cool blue. I’m an Inspiring Helper. See Figure 2 for details of the ‘energy colours’ and Figure 3 for personality type. **A model of personality theory based on Swiss psychologist Carl Gustav Jung’s 1921 work, ‘Psychological Types’.

Figure 2: Energy colours

Source:www.mrdynamics.com/insights-discovery/insightsdiscovery-colours/ (accessed 23/02/17)

Figure 3: Personality type

THE BENEFITS OF KNOWING THESE OUTCOMES

It helps to know how best to communicate and work with others and how they can do this in return, acknowledging that each person you work alongside has individual preferences. By knowing more about their personality type and preferences, a more efficient and harmonious working relationship can be developed. Find out more about Insights Discovery at www.insights.com/564/Insights-Discovery. html (accessed 23/02/17). Earlier this year, I attended a three-day course to learn about the ‘7 Habits Foundations’ (http://7habits.franklincovey.com/the-7-habitssolutions/). Prior to the work sessions, my manager and colleagues were asked to complete 360º reviews on me. I would do the same in return. The anonymous reviews are analysed along with my own answers about my own work style, approach to others and communication style. The report produced reflects your strengths and

Source: www.righttraxtraining.co.uk/your-development/ personality-profiling/insights-discovery/ (accessed 23/02/17)

areas for improvement in relation to the 7 habits, which are shown in Figure 4 overleaf. In essence, the seven habits are based on a lot of common sense, but it is often hard to bring this together when you’re in the midst of a busy professional and personal schedule. www.NHDmag.com April - Issue 123

SKILLS & LEARNING Figure 4: 7 Habits of highly effective people

Source: www.freebizplan.org/seven-habits-of-highly-effective-people/ (accessed 23/02/17)

HABITS 1 TO 3: MANAGING YOURSELF

This relates to our control over our work and ourselves. Habit 1: Be Proactive© By being proactive we take responsibility for our actions and make choices based on principles rather than our feelings or mood. We have the choice to improve our situation and, by taking the initiative to make changes, we can move towards positive actions. It is also important to focus on the areas where you have influence, this can be limited for some, but you can influence the way you view a situation. By changing your view or paradigm to a more positive stance, it can make a situation more manageable. Simply by changing the language you use, you can totally alter the way someone interacts with you and, therefore, bring about alternative outcomes. Instead of “I can’t, I have to, I must, It’s impossible”, try, “I can, I will, I choose to”. Even your body language will alter as you change your verbal output to a more positive mode. 56

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Habit 2: Begin with the end in mind© This relates to our ability to clearly define our goals and where we want to get to. By having clear goals you can plan how to get there. You want to be successful, but what does success look like for you? How will you know when you’ve achieved success? By understanding your end goal, whether in a professional or personal capacity, you can avoid climbing a ladder of success which is placed up against the wrong wall. In other words, avoid being a busy fool! Habit 3: Put first things first© This is the ability to organise yourself and your time. It’s about making room for the ‘big rocks’ in your life, which are often work, home life, personal development, e.g. going to the gym, learning how to play a musical instrument, or, whilst at work, going on that course! Those rocks will always be there but the smaller pebbles, e.g. the emails, the messages, the office distractions etc, can fluctuate and prioritisation of these things is key to avoiding a crisis.

Figure 5: The four quadrants of activity

Source: www.prudentmoney.com/are-you-a-quadrant-1-or-quadrant-2-investor/

Figure 5 shows the four quadrants of the time matrix®, which shows the most and less effective ways to manage your time. Take a look to see where you spend most of your time. Could that change? In an ideal world we would all spend more time living in Quad II, however, the nature of our work and limited resources (time, financial or human) means we’ll spend a sizable portion of time in Quad I. The other Quads are all risks to our time spent in Quad II and we’re all guilty of visiting these. By working out your ‘big rocks’ and making them the priority, which takes discipline and will be hard initially, the smaller pebbles should fit amongst them when prioritised. The emotional bank account (EBA) This bridges the gap between managing yourself and leading others. It’s the trust that exists in our various relationships. In order to build and strengthen our relationships there has to be some give and take. This relates to how you respond to the needs of others; for example, do you willingly help your colleagues? Do you show courtesy and care? Do you follow through on commitments? Can you apologise when you’ve made a mistake? These are all potential withdrawals or deposits in a person’s EBA. To develop a strong relationship, know the person’s currency. What

would be a deposit in their EBA? This will alter from colleague to colleague, but it’s essentially that old adage of know what makes people tick. Just knowing about these things isn’t enough; being sincere about the deposit matters too. Relationships take time to grow strong, so making small deposits will build up. At times, it’s unavoidable, but where possible, avoid making a withdrawal. HABITS 4 TO 6: LEADING OTHERS

Habit 4:Think Win Win© This habit helps us to seek mutual benefit in all that we do. Team working is vital across all kinds of workplaces and personal situations; however, our competitive nature can get in the way of making the best of what we have when working with others. Maximising abundance comes from setting aside your competitive edge amongst your colleagues and family. This may be challenging when you are working with others who aren’t able to see the benefits of cooperative working in order to seek benefits for the team or work partners as whole. Competitiveness has a role to play in our personal and work lives, but true Win Win© situations and robust long-term relationships come from genuine co-operation, where trust, respect and willingness amongst all parties can be demonstrated. www.NHDmag.com April - Issue 123

SKILLS & LEARNING Habit 5: Seek first to understand, then to be understood© In order to communicate effectively we must understand one another. You know what you’re thinking and why, but the people you work with or your family don’t always. This habit teaches us to try to understand another person before presenting our own point of view. It’s important to give people the respect of listening and then answer. Our reflective and empathic listening skills are key here. Ask yourself, do the people around you feel that you really understand them? Do you regularly interrupt, only agree or disagree, judge, probe too much, or tell your own story when listening to others? It’s important to explain to others that you seek to understand (your intent) and listen to their narrative. Listen to understand rather than to simply reply. This can help to get to the heart of what really matters to the other person or team members. Reflecting their feelings and words will demonstrate that you are listening, e.g. you feel anxious about your exams, tell me more about this. Once you feel confident that others feel understood, you can move forward and share our own point of view. Asking the other person if they would be willing to listen to your point of view and then using ‘I’ messages, are important here: “I feel, I think, I’d like to share, I can see”. These are non-confrontational and can mean a deposit in the emotional bank account as opposed to a withdrawal if using ‘you’ messages: “You are, You have, You haven’t”, which can be considered an accusation or an attack. A clear answer, or solution, may not be frank from this conversation, but it can lead to improved working relationships where future solutions and answers can be achieved. Habit 6: Synergize© Synergy is the effect of all of the other habits working together. Collaborating together to create third alternatives rather than settling

for a compromise. Working together to create something that would have been realised had the individuals worked alone is a third alternative. Compromising can mean a diluted version of a great idea or strategy, whereas synergy leads to a third alternative - ‘an idea or solution that goes beyond ‘your way’ and ‘my way’ to a better, higher way that neither could have created by oursleves’2. Embracing and utilising the differences and diversities of your team and work colleagues, recognising them as strengths, can lead to greater synergy. Devising a table which lists team members, their role and their strengths, e.g. Natural Leader, Communicator, Problem Solver, Planner, can highlight best ways to delegate tasks and bring the most to the project in hand. HABIT 7: DAILY PERSONAL RENEWAL

Habit 7: Sharpen the saw© This habit is basically about looking after you and caring for your mind and body on a daily basis. In order to be successful in our personal and work lives, we must value, preserve and enhance ourselves. This relates to our health: physically, mentally and emotionally, regularly renewing the four dimensions of our nature: mind, body, spirit and heart. Taking time on a daily basis to attend to your health and wellbeing is essential. Exercise, good nutrition, rest for the body and spending time with friends and family are all for the heart. Reading, writing, learning, or study are for the mind. Creative or religious pursuits, spending time with nature, inspirational literature or serving others are for the spirit. The 7 Habit course is three days of valuable insight into respectful self-improvement. It teaches effectiveness with kindness and appreciation of others. It’s hard to condense the full extent of the information in to a short article for Network Health Digest, but the overall experience for me has been extremely positive and it will have a great impact on my future working style and approaches.

References 1 The Chartered Institute of Personnel and Development (2015). Learning and Development: Annual Report www.cipd.co.uk/knowledge/strategy/ development/surveys# <accessed 23/02/17> 2 Franklin Covey (2016). The 7 Habits of Highly Effective People - Perspective that inspires improvement: 7 Habits Foundations 3 Covey SR (2013). The 7 Habits of Highly Effective People: Powerful Lessons in Personal Change. Staten Island, USA: Simon and Schuster. 4 Honey P and Mumford A (2000). The learning styles helper’s guide. Maidenhead: Peter Honey Publications Ltd.

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