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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
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CONTENTS
11 COVER STORY Follow-on formula: friend or foe?
6
News
8
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
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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.
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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
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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.
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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
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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
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