Network Health Digest - May 2017 by NH Publishing Ltd

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

NHDmag.com

May 2017: Issue 124

PARENTERAL NUTRITION: A DIETITIANâ&#x20AC;&#x2122;S ROLE KETOGENIC DIET DYSPHAGIA MINDFULNESS WEIGHT MANAGEMENT

Plus

Paediatric Supplement

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.

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CONTENTS

11 COVER STORY Parenteral nutrition: a dietitian's role

News

Latest industry and product updates

40 MINDFULNESS Helping to reduce mindless eating

16 Enteral feeding Student training

20 WEIGHT CONCERNS Diet and non-diet persepectives

44 BDA update Research Symposium 46 Face to Face With Durwin Banks

Linseed farmer

27 Dysphagia Puree diet week challenge

48 Web watch Online resources

33 PHYTATES & CEREALS Mineral absorption and pytate content

and updates

50 Events & courses, dieteticJOBS Diary dates & jobs

37 Ketogenic diet The effects on adults with epilepsy

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

@NHDmagazine

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

www.NHDmag.com May 2017 - Issue 124

ISSN 2398-8754

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.

FOCUS ON Paediatrics View the Paediatric Nutrition Supplement at the back of this issue

May. The fifth month of the year, named after the Greek goddess of fertility, Maia. Often viewed as a month of abundance and success, throughout history it has provided some pretty significant movers and shakers in the world. On 6th May 1956, Sigmund Freud, grandfather of psychoanalysis was born. His theories became the foundations of treating many psychiatric disorders. Modern behavioural therapies have diversified and developed since Freudâ&#x20AC;&#x2122;s time and we now see these featuring in our toolkit as therapists. This month we welcome back Nikki Brierley RD with her article on mindfulness and nutrition, which explores various techniques and their benefits. Non dietary approaches to weight management are an alternative to traditional methods, which have seen increasing interest and implementation over recent years. A name synonymous with this approach is Dr Lucy Aphramor. This month, Lucy shares an article which focuses on a stages-ofchange perspective to diet. On 12th May 1820, Florence Nightingale was born. A British nurse and health activist, she helped to shape modern clinical healthcare procedures and practices. Rachel Hall RD shares her experiences as a student trainer and her approaches to teaching enteral nutrition practice. We also introduce Bernadette Tavner Allsopp RD, too, who writes about clinical parenteral nutrition and the role of the dietitian in its initiation and management. London-based Dietitian, Kit Kaalund Hansen brings us a historical look at the research behind ketogenic diet therapy and its use in adult patients, whilst Salford Royal NHS Foundation Trust Dietitians share their journey through

a seven-day, category C puree diet challenge, providing insights into their experience and how this impacted on their day-to-day living and their future practice. Although she wasnâ&#x20AC;&#x2122;t born in May, she did accomplish something outstanding: on 20th May 1932 Amelia Earhart became the first woman to fly solo across the Atlantic, an incredible achievement for the era, both technologically and socially. Our very own soloist, freelance contributors, Ursula Arens and Priya Tew RD are in full flight for us once again this month. Priya shares some interesting insights into phytates and cereals, while Ursula brings us another F2F (Face to face) feature, where she meets linseed farmer, Durwin Banks. Our Focus on paediatric nutrition supplement will be valuable reference material with two articles from Maeve Hanan RD focusing on follow-on formulas and nutrition in schools, while Kate Roberts RD returns with an evidence-based guide to complementary feeding. Dr Emma Derbyshire provides an analysis of infant and toddler products sold in the UK and information on infant formula that contains full fat milks. The merry month of May has given us many wonderful things over the years: scientists, pioneering healthcare professionals, artists, film stars. All have brought us some inspiration to be the best we can be. Enjoy the read this month. Emma www.NHDmag.com May 2017 - Issue 124

NEWS

FOOD FOR THOUGHT

Dr Emma Derbyshire Independent Consultant 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.

GLUTEN-FREE AND OMEGA PRESCRIBING MAY BE CUT In March, NHS England announced a review after local health bosses identified £400m of spending which they believe has little or no clinical value. These proposals could see tighter restrictions or a complete ban on some products being prescribed by GPs. A provisional list of 10 products has been drawn up by NHS Clinical Commissioners (Table 1). Table 1: Products that may be cut and their annual costs to the NHS: 1.

£30.93m on Liothyronine to treat underactive thyroid

£21.88m on gluten-free foods

£17.58m on Lidocaine plasters for treating nerve-related pain

£10.51m on Tadalafil, an alternative to Viagra

£10.13m on Fentanyl, a drug to treat pain in terminally ill patients

£8.32m on the painkiller Co-proxamol

£9.47m on travel vaccines

£7.12m on Doxazosin MR, a drug for high blood pressure

£6.43m on rubs and ointments

10.

£5.65m on omega-3 and fish oils

The evidence submitted to NHS England claims that the prescribing of gluten-free products dates back to the 1960s. It goes on to make the case that this was a period when there was not the choice there is now in supermarkets, shops and indeed online. The same could be said for omega-3 and 6 supplements. So, prescriptions for these may not be as necessary as they once were. So, more cuts on the horizon it seems. One question, however, is whether people purchasing these without a prescription receive the same level of guidance. For example, certain doses, or ratios of omega-3 and 6 fatty acids may be required. Also, a general mention about the range of products that contain gluten may be needed. It is questionable too, whether poorer sectors could afford these specialist products. So, the jury is out on this one it seems. For more information, see: www.bbc.com/news/health-39413915

Network Health Digest (NHD) is published 10 times a year. Four issues are DIGITAL ONLY. That means you can only read them online at www.NHDmag.com by logging in with your subscriber details.

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T The Magazine for Dietitians, Nutritionis ts and Healthcar e Professionals 124

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PARENTERAL NUT RITION: A DIETITIAN’S ROL E KETOGENIC DIET

ENTERAL FEEDING DYSPHAGIA WEIGHT MANAGEM ENT

www.NHDmag.com May 2017 - Issue 124

Plus

Paediatric Supplement

NEWS IRON AND ADHD It is relatively well known that omega-3 and 6 fatty acids can have a role to play in the management of attention deficit hyperactivity disorder (ADHD). Now, a new meta-analysis has looked at the role of iron. Iron is a valuable trace element that also plays a role in brain function and dopamine systems. The paper pooled findings from 11 studies. Findings showed that serum ferritin levels were lower in ADHD cases. However, serum iron levels were not related to ADHD. These are intriguing results showing that serum ferritin levels are lower in children with

ADHD. Whether this is a consequence or cause is yet to be determined. That said, iron status should be considered in future studies looking at ADHD in children. For more information, see: Wang Y et al (2017). PLoS One Vol 12, No 1: pg e0169145

LATEST ON IRON BIOAVAILABILITY Iron deficiency is one of the most common deficiency disorders worldwide after vitamin D deficiency. Iron shortfalls are also common in the UK, with half (48%) of British young women having iron intakes below the Lower Reference Nutrient Intake (level below which deficiency is likely to occur), along with a quarter (27%) of women aged 19 to 64 years.1 It should be considered that the iron we ingest is not necessarily what we absorb and utilise. Indeed, a whole host of factors can affect iron bioavailability, from phytates found in beans, grains and nuts, to tannins in coffee and polyphenols in some herbal teas, cereals, wine and legumes, along with minerals such as zinc and calcium. New interactive tool A new study published in the American Journal of Clinical Nutrition2 has now developed an interactive tool to predict the amount of iron that is absorbed in iron sufficient adults not taking iron supplements. Data was obtained from UK adults taking part in two different studies. Mean iron intakes and serum ferritin levels (a marker of iron stores) were derived. Iron intakes were: 13.6mg/d in men, 10.3mg/d in premenopausal women and 10.9mg/d in postmenopausal women. The model also estimated mean dietary iron absorption (Table 1). It can be seen that age can lead to reduced iron absorption, especially amongst postmenopausal women. Interestingly, meat was found to be a key factor contributing to differences in iron status. Table 1: Calculated mean dietary iron absorption (%) based on ferritin levels. Mean dietary iron absorption (%) Serum ferritin levels (mg/L)

MEN

PREMENOPAUSAL WOMEN

POSTMENOPAUSAL WOMEN

22.3

27.2

18.4

16.3

17.2

12.7

11.6

10.6

10.5

Overall, this is an important new study. That said, it should be considered that this was a population with sufficient iron levels at baseline. Findings are likely to be different again (and absorption rates probably higher) if applied to those with iron deficiency or iron deficiency anaemia. References 1 Bates B et al (2016). National Diet and Nutrition Survey Results from Years 5 and 6 (combined) of the Rolling Programme (2012/2013-2013/2014). PHE and FSA: London 2 Fairweather-Tait S et al (2017). American Journal of Clinical Nutrition [Epub ahead of print]

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NEWS MILK OLIGOSACCHARIDES VARY WIDELY There is no doubt about it, human milk is a complex fluid. It contains innumerable substances, with one of these being a group of complex carbohydrates known as human milk oligosaccharides (HMOs). These are thought to have multiple biological activities, from supporting postnatal brain development to shaping the infants gut microbiome. Now, new research has measured HMO profiles across different profiles of healthy women. Breast milk was collected from 410 women in 11 international cohorts. Research showed that there was great variation in HMO profiles. For example, Swedish women had >4x higher mean 3-fucosyllactose (an oligosaccharide) levels than Gambian women. Maternal age, weight and body mass index also affected HMO levels, along with possible genetic differences. These are important findings showing that HMO profiles are not the same for any one woman who is breastfeeding. Genetics may have a role to play, though more research is needed to delve deeper into this. For more information, see: McGuire ML et al (2017). American Journal of Clinical Nutrition [Epub ahead of print]

COELIAC AWARENESS WEEK 8-14 MAY 2017: THE GLUTEN FREEVOLUTION! This year, Coeliac Awareness Week shifts focus to eating out, as it starts with the launch of ‘the Gluten Freevolution’, a campaign for better gluten-free food, whether you’re eating out or grabbing something quick on the move. And there is still time to get involved. Awareness of coeliac disease and the glutenfree diet is growing, but there is still a lot to do in making people aware of the symptoms and how they affect people differently before diagnosis. Symptoms can often be mistakenly linked to other conditions and may not be treated seriously enough for people to seek further help. Creating a stronger link between symptoms and coeliac disease will help people become more informed, empowered and confident to have their symptoms investigated and seek a diagnosis. Improving awareness of coeliac disease amongst healthcare professionals is also hugely important. This will in turn help to reduce the time it takes to get a diagnosis and

tackle misdiagnosis of other conditions, such as irritable bowel syndrome (IBS). The Gluten Freevolution is all about trying to improve the amount and quality of the gluten-free food products available. You can get involved to help show the demand for better gluten-free. Although the campaign is launched in Awareness Week, the Gluten Freevolution is running throughout 2017, so there is plenty of time to get involved. You can: • provide feedback using one of the Gluten Freevolution postcards; • promote great gluten-free by raising a flag and sharing your image on social media; • give out leaflets to help improvements in the public sector caterers as well private businesses; • share the animated films. . . . and much more! Visit www.coeliac.org. uk for full information on Awareness Week and what you can do to help.

8 -14 May 2017 8

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NEWS

MALNUTRITION IN THE ELDERLY RESEARCH

Malnutrition currently affects 1.3 million people over the age of 65 and, if missed, can lead to further problems. It causes poor immunity, resulting in increased infections, increased doctor and hospital visits, longer hospital stays and increased dependency. Recent research has revealed significant concerns amongst healthcare workers regarding treatment for patients with the swallowing disorder dysphagia. Around half of those surveyed said they had recently seen cases where the failure to give a texture modified diet had contributed to malnutrition. Nearly half also said they had not been trained on dysphagia in the previous two years and 10% had never received training.1 The findings of a study conducted by apetito and OnePoll concluded that neither the older population, nor their children, are being made aware of malnutrition by their GPs. The research of 2,000 people aged between 30 and 71 with elderly parents, discovered 79% said their parents had not discussed malnutrition with their general practitioner.2 It also found that almost half (42.6) of the UK population aged 30-50 are unaware of the serious nature of malnutrition in the elderly. The study found that four in 10 people were unaware of the symptoms of malnutrition. With statistics showing one in 10 older people over the age of 65 are estimated to be malnourished and the study highlighting how 47% donâ&#x20AC;&#x2122;t know where to seek advice on the issue, it is clear that the lack of awareness needs to be addressed. References 1 Data taken from an online survey among 213 UK-based healthcare professionals, conducted by Research Now on behalf of Wiltshire Farm Foods. Fieldwork was carried out between 11th-23rd September 2014 2 Data from a survey carried out by OnePoll of 2,000 adults aged 30-71. Fieldwork was carried out between 23rd-28th February 2017

PRODUCT / INDUSTRY NEWS KETOCARE FOODS ON PRESCRIPTION KetoCare Foods is a team of enthusiastic dietitians and cooks who are passionate about the science behind the ketogenic diet and working closely with teams of dietitians. From the beginning, our ethos has been determined by wanting to make a positive difference for patients by making the diet feel more 'normal'. With this in mind, we developed a range of Classical 3:1 Ketogenic dietary products that are now available on prescription in the UK. Our products are all ready to eat, making them a great addition to the current ketogenic dietary therapies in the UK, offering flexibility and choice both to the patient and to their parents/guardians. Each product is made with natural real food, are portion controlled, have a long shelf life and stable at room temperature, making them convenient for lunch boxes, hospital stays and other occasions when home cooking may not be an option. If you feel these products may help your patients, do get in touch to request a sample box or arrange a meeting to discuss current and future products. View our full range of products at: www.ketocarefoods.com

To book your Company's product news for the next issue of Network Health Digest call

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COVER STORY

PARENTERAL NUTRITION: A DIETITIAN’S ROLE Bernadette Tavner Allsopp, Advanced Dietitian, Acute Team Lead Stoke Mandeville Hospital

Bernadette qualified as a dietitian in 1990. She works as an Advanced Dietitian in Nutrition Support. She has also worked in: Saudi Arabia, County Durham, an NGO in Sri Lanka and Kent.

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

Over the past 13 years as a nutrition support dietitian at Stoke Mandeville Hospital (SMH), part of Buckinghamshire Healthcare NHS Trust, I have had the opportunity to develop and work with a proactive and supportive Nutrition Team. Approximately 45% of my clinical time is spent in parenteral nutrition (PN) work, completing wardrounds,8 development work, training or collating data for the safe use and provision of total parenteral nutrition (TPN) for the trust. Stoke Mandeville, a district general hospital, is the site for surgical emergency and acute gastroenterology work and hosts the main Intensive Care unit for the Trust. I work closely with a nutrition and surgical pharmacist in addition to a Lead Nutrition Consultant and Gastroenterologist and Nutrition Nurse Specialist. Our team is also supported by a General Colorectal Surgeon and other members of the multidisciplinary team (MDT), such as the Out-patient Parenteral Antimicrobial Therapy (OPAT) Clinical Nurse Specialist Team. Effective Nutrition Teams are vital to ensure the appropriate use of and safe provision of PN in a hospital setting.1 The pharmacist and I complete a Ward-based bedside assessment of patients receiving TPN three times a week (Monday, Wednesday and Friday). As we do not cover weekends, we have found this to be more efficient than daily ward rounds. Although TPN is never an emergency treatment,2 the on-call pharmacist will facilitate the TPN prescription if the requesting Consultant team provide sufficient evidence of need. On Fridays, we are joined by our Consultant and Nutrition Nurse. We generally accept

referrals before 12 midday Monday to Friday, but can be more flexible if we have capacity. Our trust strongly supports interdisciplinary working and, as such, we have close and supportive working relationships with our Anesthetic and Surgical colleagues, enabling joint decisionmaking in complex nutrition cases. Currently, we stock one type of TPN bag with a three-month expiry which contains: 2,520mls, 10gN, 1,750kcals. This type of bag is sufficient to meet the initial requirements of our patients. Results from our audit monitoring suggests two-thirds are likely to be at risk from re-feeding syndrome with a third requiring 50% nutrition requirements initially. All other TPN is out-sourced to a company which make up the ‘Bespoke TPN’ regimens required. This method of provision is required as we have had limited pharmacy storage and no capacity in pharmacy to make additions to bags. The advantage of using bespoke TPN has been to design regimens to optimise wound healing and nutrition support. However, this has also had a cost implication. The pharmacist and I are working to look at more costeffective ways of providing TPN. TPN ASSESSMENT AND MONITORING

Working in TPN rarely, or for the first time, can appear daunting. There are some differences from enteral nutrition, but the principles regarding: Dietetic diagnosis, outcomes and goal setting remain the www.NHDmag.com May 2017 - Issue 124

CLINICAL

same.5 Initial assessment tools (ABCDE) and monitoring/evaluation are used and, overall, most assessment data is similar. In addition, working within a Nutrition Team and/or working with an experienced pharmacist will provide support. However, always work within your competency and manage your caseload safely. If you are lone working, never feel pressured to provide TPN. It may be better to wait until the next working day when more experienced colleagues can support your working.4 TPN is usually initiated over a 24-hour period. The feed time can be reduced to a minimum of 12 hours over several days once the feeding aim has been reached and the patient has achieved glycemic stability. Initial assessment Anthropometry: weight, weight loss, BMI. Also consider size of wound areas (pressure areas, abdominal wounds). Biochemistry: i) Biochemical trends including: magnesium, phosphate and corrected calcium, as these can be added to TPN regimens. ii) Blood glucose monitoring. All TPN patients require blood glucose checks, it provides an indicator of sepsis as well as a marker for diabetes. iii) Check electrolyte content of intravenous (IV) fluids. 12

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Clinical: i) Fluid balance. Bedbound surgical patients can often become fluid overloaded. Assess losses from; gastric, vomit, wound or drains, stoma, urinary or faecal. ii) Temperature. This will affect stress factor calculations and is an indicator of potential sepsis. iii) Respiratory function and heart function. Will the TPN fluid volume adversely affect the patientâ&#x20AC;&#x2122;s function? iv) Medication review, particularly prokinetics, antiemetics, antibiotics and IV fluids. Dietary: i) Usual eating pattern, changes in eating pattern. ii) Number of days with insufficient intake / Nil By Mouth (NBM). iii) Estimated risk of refeeding syndrome. Consider your dietetic diagnosis, outcome and goals Estimate requirements: i) Calculate protein and energy requirements. ii) Provide sufficient protein, non-protein calorie:nitrogen (NPC:N) ratio to meet your outcome. Following your assessment, you will have a substantial amount of information with which to work. However, the most important starter questions need to be:

Approximately 85% of our referrals do commence TPN on assessment. However, 15% will move to enteral nutrition or oral intake.

• Will this individual benefit from TPN regardless of its risk? • Is the ‘gut’ working? Approximately 85% of our referrals do commence TPN on assessment. However, 15% will move to enteral nutrition or oral intake. By proactive working with the referral team, TPN can be saved for the most appropriate cases: reestablishing nutrition via the enteral route faster, decreasing hospital stay and potential infection risk, as well as being more cost effective. Additional information required prior to starting: • Can the referral team suggest how long TPN will be required? • Which venous assess is available? • Is the patient easy to cannulate? The age of the patient and the current patient length of stay will determine peripheral access tolerance with a ‘20G (gauge)’ flow rate 61ml/min, ‘22G flow rate 36mls/min for adults with small veins or ‘24G’ flow rate 22ml/min for elderly with fragile veins should be tolerated.6 PN planned for three to 10 days may be tolerated peripherally.7 A 5mg glyceryl trinitrate (GTN) patch upstream from the cannula8 can be recommended to reduce the risk of phlebitis. Moving the cannula every 48 hours can further reduce the risk; the high osmolarity of the TPN solution irritates veins. Alternatively, a central line such as a dual lumen peripherally inserted central catheter (PICC line), an internal jugular, subclavian line, or a tunnelled central line (Hickman), may be. requested. Commencing a (Visual Intravenous Phlebitis (VIP) score chart is also essential.

MONITORING AND REVIEWING TPN:

Once you have recommended your TPN regimen, documented in the clinical notes and it has been prescribed by the pharmacist, a review within 48 to 72 hours to assess progress both from a physiological and a compliance point of view is required. The following need to be assessed: • Anthropometrics and wound changes if measured. • The 3 Bs: i) Blood tests - what are the blood trends including urea and electrolytes (U&Es), liver function tests (LFTs), magnesium, bone profile (calcium, phosphate) and hematology. Is the patient under/over-hydrated? What electrolyte additions have been infused besides the TPN? ii) Blood glucose - are levels within range and measured at least twice daily? If >10mmol/L, investigate cause: diabetes, glucose intolerance, insulin insufficiency, sepsis. Consider involvement by Diabetes Specialist Nurse/Specialist Team for sepsis. iii) Balance - what are the loss trends? Do the gastric residual volumes (GRVs) suggest enteral nutrition can be recommended? Is there sufficient urine being passed? Has the patient passed flatus or stool? Are medications such as prokinetics, oral Magnesium or antibiotics contributing to large faecal losses, >500mls/d or large stomal losses >1,500mls/d. Stopping metoclopramide or oral magnesium can work wonders in reducing losses from what is perceived as ‘malabsorption’. www.NHDmag.com May 2017 - Issue 124

CLINICAL Table 1: Parenteral electrolyte requirement in practice (adapted from section 3.11 from Pocket Guide to Clinical Nutrition10)

1-1.5mmol/kg

High losses: GRV, stoma, fistula or faecal can result in high sodium requirements. Remember 0.9%NaCL contains 150mmolNa/L. Continue to add sodium until normal levels achieved.

Potassium

1-1.5mmol/kg

Wound, gastric and faecal losses can deplete body potassium. A rule of thumb suggests to improve serum K+ by 0.3mmol/l you may require 100mmol K+.

Magnesium

0.1-0.2mmol/kg

Losses again contribute to low body stores particularly in intestinal failure.

Phosphate

10mmol/1000kcals

Low levels are often seen in re-feeding and pancreatitis.

Calcium

0.1-0.15mmol/kg

Minimum content of calcium is usually required.

Other

Zinc, selenium, copper may need to be added to TPN > two week duration. Manganese monitoring may be required with long-term TPN to reduce risk of toxicity.

Sodium

• Access and VIP chart: Is the VIP ‘0’? Discuss with nurses and team if VIP >1 and request specialist intervention from an IV/ OPAT Nurse. Is the access still appropriate for the patient? • Requirements: Does the current TPN meet patient requirements/recommended intake? Should TPN be used exclusively, or can trophic feeding begin? • TPN regimen: Has the regimen been countersigned by a prescriber? Has the prescriber taken into account TPN volume and electrolytes when prescribing IV fluids? • Clinical changes: Has anything significantly changed that needs to be taken into account which will affect the regimen being proposed? In addition to BAPEN3 and NICE11 which provide practice guidance and standards for PN, the PN section within the Pocket Guide to Clinical Nutrition produced by the Parenteral and Enteral Nutrition Group (PENG), a specialist sub group of the British 14

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Dietetic Association,10 is one of the best tools to highlight the essential principles of TPN and ‘learn the ropes’ around the use and monitoring of TPN. WHAT ABOUT BESPOKE/TAILORED REGIMENS?

There are several ways to calculate TPN regimens. Below is one example: 1. Calculate Nitrogen (g) then convert to protein (g). Multiply by 4 giving total protein calories. 2. Calculate desired energy intake. 3. Subtract protein calories from desired calories. This will leave NPC. 4. NPC can then be divided into carbohydrate (glucose calories): fat (lipid calories). The ratio can be divided into a 70:30, 60:40 or 50:50 ratio 5. Lipid has been shown to be immunosuppressive and can lead to cholestasis.11 It is recommended not to exceed 1.5g lipid/ kg. In addition, sick septic patients are recommended a lipid load of 0.8-1g/kg. Therefore, calculate g lipid/kg and multiply by 9 to give lipid calories.

. . . TPN can be saved for the most appropriate cases: re-establishing nutrition via the enteral route faster, decreasing hospital stay and potential infection risk, as well as being more cost effective.

6. Subtract lipid calories from NPC to give glucose calories. 7. Glucose calories can then be converted to grams by dividing by 3.7. Glucose provision must exceed 125g/d as this is the minimum required for brain and cardiac function. If this method is used it is unlikely you will exceed GOR (glucose oxidation rate). Exceeding GOR will lead to the deposition of fat. 8. Determine electrolytes required. Generally, the focus is on five main electrolytes (see Table 1). 9. Choose a total fluid volume: a volume of <1,250mls is not recommended as the resulting osmolarity of the solution may be unstable. Volumes of up to 4l-5l can be infused over 12 hours; however, specialist reinforced bags are required because of the danger of the bag splitting and the difficulty in attaching it to the drip stand. Most regimens run with a 2-3l content. 10. Include a vitamin and mineral supplement such as ‘Cernevit’ and ‘Additrace’. 11. NB: a) Non-standard bags must be given via a central line only. Osmolarities which exceed >800mmol/l can cause severe phebitis if infused peripherally. b) Always check your working with an experienced colleague (TPN pharmacist, Aseptic pharmacist or the Out-Source TPN provider) for stability.

AUDITING TPN USAGE

Annually, we receive about 130 referrals for TPN at SMH with our sister hospital, Wycombe Hospital, receiving about 20 referrals. About 10% of patients have TPN for >two weeks with only a handful each year requiring admission to a tertiary centre for home TPN. The careful monitoring of TPN referrals, the provision of TPN and any line sepsis resulting from a TPN line is essential to: a) check we are compliant with guidance from ‘NCEPOD A Mixed Bag (2010)’,12 to achieve an infection rate of <4 infections/1,000 TPN days; b) evaluate cost savings for the Trust and c) determine the importance of the Nutrition Team. TPN provides a considerable amount of interesting and rewarding work for the dietitian. The variety of work from designing regimens, proactive MDT working, sharing expertise in training, dealing with complex surgical cases, and managing complex feeding decisions, makes each working week very different. Despite being in this post for 13 years, longer than any previous position, my TPN clinical work offers regular learning opportunities and a great sense of achievement.

With thanks to : Dr Sue Cullen, Gastroenterologist BHT www.NHDmag.com May 2017 - Issue 124

CLINICAL

STUDENT TRAINING IN ENTERAL FEEDING Rachel Hall Dietitian, Betsi Cadwaladr University Health Board (East)

Rachel has worked as a Dietitian for the last five years and currently works in Gastroenterology and Obesity Management, as well as being one of the Lead Student Trainers.

Nasogastric feeding is a common request for students to observe and participate in throughout their practice placements. However, are students really prepared for ‘real life’ tube feeding? From experience I have found that students can struggle to grasp nasogastric feeding in practice, despite their knowledge of the theory. I was hoping to write this article and look at what guidance and research had previously been carried out into teaching student dietitians in this important area of practice. However, the evidence in terms of teaching students whilst on practical placement, is very limited. What I did come across was a brief statement about artificial feeding in the BDA curriculum guidance from 2013,1 which stated that Graduate dietitians are expected to have an ‘Extensive critical, integrated and applied knowledge of dietetics for the prevention and treatment of disease’, which includes artificial nutrition with enteral and parenteral feeding as one of its points. This is a very brief statement to say the least. I thought, therefore, that I would look at the tutorial which I use with students and the theories of adult learning. ADULT LEARNING2

The theories of adult learning (Andragogy) where first discussed by Malcolm Knowles in the 1980s. Through his work, he identified a number of key characteristics of Adult Learners. Our dietetic students will be aged approximately 20 plus when they commence their first practice placement, so these theories will apply to them. Knowles identified the key characteristics of the following points: 16

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• Self-concept: self-direction. • Learner experience: Experience developed though life. • Readiness to learn: learning becomes orientated to developmental tasks of their role. • Orientation to learning: learning adapts to a more problem based approach. • Motivation to learn: becomes internal. He then suggested that there are four principals of andragogy which include:3 • adults being involved in the planning and evaluation of their training; • learners’ experience, including mistakes become a basis of learning activities; • relevance: adult learners are more focused on aspects which will be involved in their job; • problem centred, rather than content centred approach. Therefore, as practice placement providers, we need to ensure that our tutorials take into consideration these learning theories. As well as taking into account the specific learning styles of the individual students. Learning styles:4 • Theorist - understand theory behind practice.

Table 1: Summary of the case studies

Case study 1:

A stroke patient who has been referred day one post admission, with a past medical history of hypertension and Type 2 diabetes. The patient is prescribed Ramipril, Gliclazide and Simvastatin. Weight: 90kg Height: 5ft 3ins

Case study 2:

A patient who has been admitted following a VF arrest. They have been nil by mouth for three days before being seen by Speech and Language who advise six teaspoons of Stage 2 thickened fluids and six teaspoons of level B/C diet maximum hourly. Weight: 57kg Height 5ft 6ins

Case study 3:

A stroke patient who has been admitted to hospital for eight days before the medical team request nasogastric feeding. Ulna:22cm Weight: 46.9kg In all case studies, blood results are provided for the initial assessment.

• Activist - students who learn by doing. • Reflector - students who learn by observing and thinking about what has happened. • Pragmatist - students who need to see how to put learning into practice. TUTORIAL

The tutorial that I use with students, although not exhaustive, covers points that have come to light through spending time teaching students the practicalities of enteral feeding and continues to be an evolving teaching tool. Initially the tutorial starts with some basic questions on enteral feeding: 1. What are the routes of enteral nutrition? 2. What are the indications for enteral feeding? 3. How do you confirm the position of nasogastric feeding tubes? 4. What are the advantages and disadvantages of bolus and continuous feeding? We include these questions as a recap of what will have been learnt at university to link theory into the students’ practical training. This also links into the guidelines which should have been highlighted at university, such as NICE guideline 32: Nutrition Support for Adults (2006) and the Guidelines for Enteral Feeding in Adult Hospital Patients (2003). It is essential for students to be aware of the practical implications of these documents, and also allowing them to recap what is written in The Manual of Dietetic Practice.

We also refer to local policy in the tutorial and highlight the need to seek out the local policies with regards to tube feeding in future Trusts where they work, as these local policies may differ to some of the generic guidelines. Following these general questions we then move onto case studies. We include three case studies that cover the basic patient types which students may come across both during placement and as a basic grade: • A patient with a BMI of over 30kg/m2 • A refeeding patient • Patients who need progressing from nasogastric feeding to diet • Patients who need their feeding method switched from continuous to bolus. Initially the questions are based around calculating anthropometrics, nutritional requirements, devising feeding regimens and entries (including nutritional diagnoses) that would be suitable for the medical notes. In addition to the above case studies, the students are also asked to consider what would happen when multiple nasogastric tubes are required daily and the patient remains nil by mouth. Students are asked to think about how nasogastric feeding impacts on the rehabilitation of the patient and the care provided by other members of the multidisciplinary team. This helps the students to think holistically and to work alongside the wider multidisciplinary team, and so links back to the learning outcomes of the practical placements. www.NHDmag.com May 2017 - Issue 124

CLINICAL

The learning styles of the individual students on placement can be suggestive of when your individual students would most benefit from participating in an enteral feeding tutorial. Although the aim of the tutorial is to ensure that the students are comfortable and competent with nasogastric feeding, as this is a learning tool, there are always some aspects of the tutorial which require further discussion during the session to clarify these points for the students. These points include the following: • Devising the regimen - discussions focus on the timings and rates of continuous feeds, as well as the types of feed to use, especially for bolus regimens. • Frequency of review - although students are not incorrect with this aspect, we do discuss the practicalities of reviewing patients when you have a caseload to manage. • BMI greater than 30kg/m2 - the difference in requirements for individuals over 30kg/ m2 is almost always missed by students and is, therefore, why this has been included to highlight this to students.

CONCLUSION

The tutorial does take into account the characteristics and principals of adult learning set out by Knowles and also takes into account the four different learning styles. The learning styles of the individual students on placement can be suggestive of when your individual students would most benefit from participating in an enteral feeding tutorial. However, I would suggest that this be completed early on in their second placement, as a way to consolidate their learning and put theory into practice before starting to devise feeding regimens on the wards. I am aware that this is very much my opinion and, therefore, other dietitians and clinical trainers may have their own opinions with regards to tutorials and enteral feeding. But hopefully this may shine a light on an area of Dietetics which may require more research.

References 1 British Dietetic Association (2013). A Curriculum Framework for the pre-registration education and training of dietitians. Accessed 19/02/2017; www. bda.uk.com/training/practice/preregcurriculum 2 Pappas C (2013).The Adult Learning Theory - Andragogy - of Malcolm Knowles. Accessed 08/03/2017; https://elearningindustry.com/ the-adult-learning-theory-andragogy-of-malcolm-knowles 3 Culatta R (2015). Andragogy (Malcolm Knowles). Accessed 08/03/2017; www.instructionaldesign.org/theories/andragogy.html. 4 Mobbs R. Honey and Mumford. Accessed 08/03/2017; www2.le.ac.uk/departments/gradschool/training/eresources/teaching/theories/ honey-mumford

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WEIGHT MANAGEMENT

Lucy Aphramor Dietitian, Owner, Well Now Lucy Aphramor is a radical dietitian and poet. She developed the Well Now approach to ensure nutrition practise bridges self-care and social justice in dietetics.

A STAGES-OF-CHANGE PERSPECTIVE TO DIET, NON-DIET AND HEALTH-GAIN APPROACHES FOR WEIGHT CONCERNS As nutrition professionals, we are all too aware of the diet cycle. Initial shortterm weight reduction is almost inevitably followed by regain, and rebound to a higher weight is common.1 Chronic dieters experience guilt, anger and bewilderment, when, despite everything they try, weight stays the same and eating remains a battleground. When we meet someone who is considering weight loss again, how can we best support them? Given that we will have already considered goal setting, portion sizes, meal planning, emotional drivers, physical activity, self-monitoring, motivational interviewing and more, the question becomes, “What can I offer that is different?” It is this recognition of the need for changing our behaviour as practitioners that motivates the search for an alternative approach to weight concerns. The Trans-theoretical Model of behaviour change describes the stage of pre-contemplation as one where people are often unaware that their behaviour is problematic and has negative consequences. The growing interest among nutrition professionals in critiquing conventional weight management, signals a shift from pre-contemplation to contemplation, where the change in question is our behaviour in addressing weight concerns. CONTEMPLATION I: OUTLINING A CASE FOR CHANGE

In the contemplation stage, someone acknowledges a behaviour as problematic and considers the pros, cons and ambivalences around changing the behaviour. There are obvious downsides to promoting weight loss (Figure 1). Our everyday experiences remind us 20

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that body dissatisfaction is rife even among a non-clinical population with dieting and fat-phobia staple conversations. Shame and guilt around eating and weight serve to further interrupt people’s ability to feed themselves well. When our clients are parents, body shame and disconnect may be passed on intergenerationally, disrupting children’s early developmental pathways around attachment, emotional regulation and body trust. The weight cycling of the dietdespair-diet cycle is far from benign, with physiological as well as emotional consequences:2 ‘Weight cycling is a common condition as only a minority of people who lose weight through weight management interventions are able to maintain their weight loss…Weight cycling is a risk factor for all-cause mortality and cardiovascular mortality (hazard ratio (HR) approximately 1.8 for both).’ Other unintended consequences of anti-fat campaigns include sizerelated bullying and stigma. Cultural and medical narratives that intertwine health and moral worth perpetuate attitudes that treat people as more or less deserving of respect according to their body size.3 Using weight loss as an outcome can obscure health improvement when clients change selfcare patterns and remain weight stable.

Figure 1: Diet Cycle*

Meanwhile, the current approach to nutrition and weight has failed to reduce social inequalities in the health conditions it targets, such as heart disease, diabetes, and hypertension. Other conundrums persist when we focus primarily on lifestyle change as the route to health. For instance, how can we respond meaningfully when we are working with people reliant on a food bank?4 How can we make sense of research that links chronic stress with poorer metabolic health, such as racism and hypertension, a link that is independent of lifestyle?4,5 We could continue adding examples of the cons, how and why the current approach to weight concerns is failing people. In so doing, it becomes apparent that changing our behaviour as health practitioners is imperative, for it would

be professionally reprehensible to continue down a path that has proven not just ineffective but harmful. The fact is, that telling people to eat less and move more hasnâ&#x20AC;&#x2122;t made us any thinner, healthier or happier as a population. The good news is that there is an alternative. So, what of the plus side and ambivalences? An obvious pay-off from continuing to promote weight loss is that we donâ&#x20AC;&#x2122;t have the uncertainties of change. Imagine having a conversation with your peers, students, managers and friends about changing this behaviour. By reflecting on what this might feel like, we bring into focus some of the gains from recommending weight loss. It can be uncomfortable to grasp that our first duty is not to support the party-line, follow department protocol, or keep our head down, it is to do no harm. www.NHDmag.com May 2017 - Issue 124

WEIGHT MANAGEMENT Figure 2: Well Now Cycle*

CONTEMPLATION II: EVIDENCE AND ETHICS

I began work as a community dietitian with traditional beliefs about weight, weight loss and health. With time, my certainties shifted as I witnessed failure, despair, shame and prejudice. A sense of disquiet prompted me to read the data behind various weight-loss guidelines to see where I was going wrong. This was an eye22

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opener. I had believed there was robust science showing that a calorie-deficit approach led to sustained weight loss. What I learnt is that this belief, though apparently plausible and pervasively lauded, derives not from science but from pseudo-science. In other words, there is no evidence that intentional calorie reduction leads to sustained weight loss. This is not the

Refusing to recommend dieting does not mean doing nothing, or giving up on people. Far from it. It means switching from asking, “How can I help you lose weight?” to “How can I support you to improve your health?” same as saying no one ever loses weight. We might even have anecdotes on weight loss successes from our own practice. However, if we commit to evidence-based practice, then the gold standard to rely on is a systematic review of randomised controlled trials of weight-loss interventions. This best available evidence shows that ‘the benefits of dieting are simply too small and the potential harms of dieting are too large for it to be recommended as a safe and effective treatment’.1 It is only possible to write weight management guidelines by ignoring this evidence, as with NICE.6 Eating disorders specialists will note another key flaw in the NICE document, namely, that authors caution against weight stigma and then adopt the very weight-correction approach that the Binge Eating Disorder Association warns against because it is harmful.7 ACTION: ALTERNATIVE RESPONSES TO WEIGHT CONCERNS

If not weight-correction, then what? Refusing to recommend dieting does not mean doing nothing, or giving up on people. Far from it. It means switching from asking, “How can I help you lose weight?” to “How can I support you to improve your health?” The shock is in realising that these two questions are not the same. The literature shows that using non-weight targets leads to long-term improvements in health behaviours, physiological and psychological measures in chronic dieters.8 There is slippage in the literature over how this approach is described. Common umbrella terms are a ‘non-diet’, ‘weight-neutral’ or ‘weight-inclusive’ approach.9 (These terms are often used, erroneously, interchangeably - a weight-neutral approach cannot also be a weight-inclusive approach - and there is a need for more robust scholarship in the

field.) More recently, a distinct weight-inclusive health-gain approach, called Well Now, has been described.10 Well Now is weight-equitable: the approach explicitly rejects neutrality, in weight or elsewhere, to advocate for interventions biased towards promoting social justice. I use the term wellness generically to cover these various perspectives and, hence, sometimes without precision, in the remainder of this article. Imagine you are having a telephone appointment with a client, Jay, referred for weight loss to treat hypertension. Six months later you make a follow-up call and things have gone well. Jay changed from shift-work to a local nine to five job and is really pleased with the changes this enabled him to make. He is eating more regularly and enjoys cooking for his family which has helped him regain pleasure from food. He now cycles to work and enjoys being active outdoors at the weekend. He has even joined a lunchtime mindfulness group. At his last job, he was bullied and reports considerable relief at feeling valued in his new team. You don’t know if his weight has changed. Figure 5 (on p25) provides a framework for considering how changes in eating, activity, mindfulness and respect might impact hypertension regardless of any change in weight. It provides a framework for illustrating that there are potential health benefits from lifestyle change and being treated with respect, which are not dependent on weight loss. Clients seek weight loss to feel better about themselves and their body, to gain control around food, to improve fitness, enhance confidence, improve diabetic control, manage hypertension and so on. We can discuss how a wellness approach is a more reliable, less harmful route to improving self-care and mood than the traditional approach.1,8,9 www.NHDmag.com May 2017 - Issue 124

WEIGHTMANAGEMENT MANAGEMENT WEIGHT

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Waymarkers for Well Now The Well Now Way - joining the dots between self-care and social justice The Well Now Way - joining the dots between self-care and social justice

Well Now - joining the dots between self-care and social justice

Our stories matter Our stories matter

Compassion Compassion

Our stories matter

Compassion

Connected eating Connected eating Kindful eating Kindful eating Connected eating Kindful eating

Realistic Realistic fitness fitness

Respect Respect

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Realistic fitness

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Bigger picture health Bigger picture ofof health Bigger picture of health

Connection Connection

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AAtake-home take-homemessage messageisisthat thatfocusing focusingonon world. world.OfOfcourse, course,Jay Jaymay mayhave havelost lostweight. weight. wellbeingthrough throughsupporting supportingcompassionate compassionate Promoting Promotingwellbeing wellbeing notanti-weight anti-weightloss loss wellbeing isisnot www.well-founded.org.uk www.well-founded.org.uk self-care, helps helps people people sustain sustain healthhealth- but butagainst againstthe thepursuit pursuitofofweight weightloss. loss.This Thisisis self-care, promotingbehaviours behaviours and attitudes morethan thana asemantic semanticdifference. difference.Untangling Untangling promoting attitudes(Figure (Figure2). more www.well-founded.org.uk Behaviours and attitudes are integrally weight, self-worth and wellbeing pivotal 2). Behaviours and attitudes are integrally weight, self-worth and wellbeing isisa apivotal relatedand andit itisisininre-evaluating re-evaluatingattitudes attitudestoto catalyst catalyst for for change change inin chronic chronic dieters, dieters, it it related Lucy Aphramor 2015. www.well-founded.org.uk. May distributed entirety, including this attribution, non©© Lucy Aphramor 2015. www.well-founded.org.uk. May bebe distributed in in itsits entirety, including this attribution, forfor nonweightthat that chronic find way outofof also alsounderpins underpinshealth health gainthrough through social weight chronic dieters find a away out gain social commerical purposes under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Licence. commerical purposes under adieters Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Licence. 4,5,10 4,5,10 thediet dietcycle cycleand andallallofofusushelp helpbuild builda afairer fairer justice. justice. the © Lucy Aphramor 2015. www.well-founded.org.uk. May be distributed in its entirety, including this attribution, for noncommerical purposes under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International Licence. www.NHDmag.comMay May 2017 - Issue 124 2424 www.NHDmag.com 2017 - Issue 124

Figure 4: Screen shot from Well Now News, NHS Highland, Issue 2 Dec 2015*

Figure 5: Well Now Table Untangling Weight, Wellbeing and Social Factors*

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WEIGHT MANAGEMENT Wellness theory is commonly misrepresented. For clarity, advocates do not suggest that everyone is already healthy whatever their size: they say that the best way to support someone to be as healthy as they can be is to promote their wellbeing. They also don’t suggest that there is a link between weight and health. Instead, they call for better quality science so that links between fatness and pathology are not exaggerated or assumed to be causal. In addition, Well Now theory integrates the social embeddedness of health. HEALTH AT EVERY SIZE®

The most widely known non-diet philosophy is health at every size or HAES. The term HAES is trademarked by the Association for Size Diversity and Health (ASDAH). The ASDAH curriculum for teaching HAES11 explains that: • ‘HAES supports people in adopting health habits for the sake of health and wellbeing (rather than weight control).' • ‘HAES encourages: - eating in a flexible manner that values pleasure and honours internal cues of hunger, satiety, and appetite; - finding the joy in moving one’s body and becoming more physically vital; - accepting and respecting the natural diversity of body sizes and shapes.’ There are also those who engage with the HAES philosophy outside of the parameters set by ASDAH, including activists, researchers and dietitians who reject the use of the trademark.12 WELL NOW

The health-gain and weight-equitable approach, Well Now, envisions a world where no one is starved of food, company or dignity. Well Now theory is compassion-centred, trauma-informed and justice enhancing. Well Now teaches kindful and connected eating, realistic fitness, body awareness and the bigger picture of health. Well Now

practice is guided by cornerstone values of personal story, compassion, connection and curiosity,4,5,10 (see Figure 3). DISTINGUISHING THEORIES

There can be cross-over in strategies between all three approaches. A dietitian advocating weight loss, a non-diet approach or the health-gain approach may encourage a client to be more aware of the taste and texture of foods, for example. However, each approach relies on a different set of core values and beliefs which impacts practice. A dietitian using a weight-correction approach sees weight management as the best way to promote wellbeing; a HAES dietitian says the best way to support someone to be as healthy as they can be is to promote their wellbeing through behaviour change and size acceptance; and a Well Now dietitian believes the best way of supporting someone’s wellbeing is by promoting health-gain and body respect for all. Here, the term healthgain recognises the pivotal intermingled roles of self-worth, fairer societies and environmental security in ensuring good health; and body respect extends beyond size diversity. Figure 3 highlights some differing values of HAES and Well Now as reflected in language and teaching style. CONCLUSION

Nutrition science is never ‘just academic’; what we say has real-life ramifications for personal and population wellbeing and equity. Ensuring that our practice is grounded in robust conceptual maps of weight and health matters for moral, ethical and epistemological (‘knowledge-building’) reasons. I began my dietetic career by recommending weight loss, then became involved in HAES and now teach, practice and develop Well Now, a professional journey shaped by my passion for dietetics and my commitment to fairness, and personal growth. I hope this article raises questions that encourage others to revisit their certainties. In this way, our collective voice can grow to ensure nutrition work enhances health and justice.

References 1 Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B and Chatman J (2007). Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer, American Psychologist, 62 (3), 220-33 2 Scottish Intercollegiate Guidelines Network (2010). Management of obesity. A national clinical guideline. Page 18 3 Rothblum E and Solvay S (Eds) (2009). The Fat Studies Reader. New York; New York University Press. * All images © Lucy Aphramor. 2017

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CONDITIONS & DISORDERS

DYSPHAGIA: PUREE DIET WEEK CATEGORY C CHALLENGE Lucy Blackstone, Rourke Thomas, Janette Banks, Sophie Johnston Band 5 Dietitians, Salford Royal NHS Foundation Trust The Team see a wide range of patients from elderly care to trauma across both the hospital and the community setting. They are all enthusiastic about seeing things from a different perspective and enjoy a challenge; what better way to learn about a puree diet than to fully immerse themselves in the experience, all in the name of charity.

As dietitians working across a variety of areas within the hospital, we all experience a vast number of patients on a modified consistency diet and, aside from tasting sessions, none of us had ever eaten a full puree meal, let alone followed a pureed diet. So, for one week in October, we decided to follow a puree diet to raise money for the Motor Neuron Disease association.

We also wanted to develop our knowledge and understanding of the difficulties faced by this patient group. Four dietitians committed to the challenge, including two vegetarians and one working Mum, and we all made it through to the end. The following questions cover what we feel to be the most important lessons learnt. WHAT WAS THE MOST DIFFICULT PART OF THE PUREE CHALLENGE?

S: The weekends and seeing friends in

the evenings was the most difficult time for me. Eating is such a social activity and it felt quite isolating to be the one in the corner eating a pureed ready meal whilst others were enjoying my favourite pizza takeaway. This really affected my mood and I found myself opting out of social activities if I knew food would be involved. I can see how this could result in social isolation over a longer period. Snacking was also difficult, as it had to be pre-planned; there was no grabbing a slice of cake from the weekly baking rota in the office!

L: I agree, as someone who doesn’t like The Authors would like to thank Wiltshire Farm Foods and Simply Puree for donating ready meals for the pureed diet challenge.

yoghurt, I found it particularly hard to find anything I liked, and the lack of savoury snack options was difficult. Similarly to Sophie, I also struggled with social situations, I took a ready meal to a friend’s birthday party and when some of the guests couldn’t even look at my meal, it made me feel a bit embarrassed. Eventually, I just avoided social situations where food was involved.

R: For me, it was the constant craving for

a little more bite! Just because a healthcare professional has advised that you follow a texture-modified diet doesn’t mean it’s going to be easy. For many patients, breaking the routine of their usual meal plans, not being able to just grab a quick snack on the way out of the house or being able to eat without thinking “Can I have this? Is this the right consistency?” could be a real burden psychologically. It’s not like becoming vegetarian, vegan or even going gluten-free, it’s not a case of restriction, it’s total reconstruction of your diet. It’s like changing all rules on something that’s second nature.

J: Fitting the diet into family life - cooking

one meal for the family and blending mine down - had time implications for a busy working mum. Blending my daughter’s apple crumble cooked at school led to cries of ‘you’re ruining it’. Blending a family one-pot meal, like fish pie, led to one big bowl of grey amorphous mush. I found the lack of crunch and variety of texture difficult for someone who doesn't like soggy cereal. This food soon became boring and so I tended to rely on yoghurts and smoothies for breakfast. IF YOU COULD GIVE PATIENTS ON A PUREE DIET ONE TIP WHAT WOULD IT BE?

S: I enjoyed mealtimes much more

when others were eating pureed foods too, which was easy for us, as the four of us were doing it together and I had continuous support. I would www.NHDmag.com May 2017 - Issue 124

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. . . puddings are very often energy dense and the great thing is that many already exist at smoother consistencies (think custard pots, yoghurts, mousses etc) . . . suggest trying to link in with other people with swallowing issues, for example, by accessing dysphagia support groups on social media sites. I would also recommend asking friends or family to eat a puree meal with you, even if it's only once a week. I found this helped me to enjoy my meal more when my boyfriend had it with me.

L: We had a lot of ready meals kindly donated

to us to try out for our challenge and this helped us to see the different options that dysphagia patients have. I personally struggled with these and didn’t realise how much importance I place on the appearance of foods. I found that when cooking meals from scratch, I was able to enjoy them more because I had seen what had gone into it. Pureeing different components of the meal separately also helped, as otherwise it all became quite boring. It’s quite easy to be tempted to puree meals in bulk and eat them for a few days in a row, but this again can lead to taste fatigue.

R: Puddings and milkshakes always have your back! Particularly in the beginning when you’re experimenting with meals, trying different flavours and just simply adjusting to life on a texture-modified diet. Milkshakes are a great way to add in some extra energy to your diet, and different combinations of ingredients (fruits, milkshake powders/syrups, honey, peanut

butter/chocolate spreads) can produce very different flavours, ensuring you only compromise on texture, not taste. Again, puddings are very often energy dense and the great thing is that many already exist at smoother consistencies (think custard pots, yoghurts, mousses etc), meaning you’ll always be able to squeeze in some extra calories even on days when your experiments haven’t quite gone to plan.

J: Don't settle for boring food; puréed food

doesn't have to be bland. Be experimental add herbs for a twist, or spices for a kick. Basil and garlic go well with tomato, garam masala or curry powder to a lentil dish. Try blending different family foods to see what works better. Blend foods separately - perhaps in bulk and freeze, portioned out for ease. Use foods with a naturally puréed texture (soups, custards, smooth yoghurts etc). Sweets and puddings seemed more acceptable in purée form than savouries, so have puddings daily, as these will also help to keep calories up. Use ready meals for increased variety. WHAT WAS THE BEST MEAL YOU ATE (READY MEAL OR HOMEMADE) DURING THE CHALLENGE?

S: My favourite meals were those with stronger flavours, mainly curries and chilli. It’s amazing how much texture can affect the tastes you experience. I like quite spicy foods normally, but www.NHDmag.com May 2017 - Issue 124

CONDITIONS & DISORDERS

I enjoyed meals that had a lot of taste to them, similar to the experience of the other dietitians. I enjoyed curries and chilli in particular I found myself adding extra herbs and spices to some of the readymade foods for an extra kick. All of the ready meal puddings were amazing; I particularly enjoyed the jam sponge and custard and would happily still eat that now I’m back on a normal diet!

L: I enjoyed meals that had a lot of taste to them,

similar to the experience of the other dietitians. I enjoyed curries and chilli in particular; I also like mashed potato anyway so was happy to eat this at almost every meal. I didn’t really enjoy the puddings because I don’t have much of a sweet tooth, so I found them quite sickly, so instead, I had stewed apple and raspberries that I had sieved and these were really nice.

R: I attempted to make Fajitas on Day 5, as I had a

real craving for them. While I couldn’t quite figure out how to blend a wrap, I did manage to blend and sieve peppers, onions and vegetarian chicken style pieces in fajita spices with chopped tomatoes. I then made guacamole on the side and had a dollop of sour cream on top. It definitely helps to cook as you usually would and blend, as Lucy says, you see the real ingredients in front of you whilst prepping your meals and this helps you to still visualise the meal as normal post blending.

J: I had blended some of my own foods together

for ease rather than separating them out, but found every mouthful tasted the same. My first ready meal, after being on pureed food for two days, was delicious. It was a chicken casserole - the vegetables tasted amazing and the mashed potatoes were creamy. I also really liked the puddings - they were more palatable and more closely resembled ‘normal’ foods. DID YOU MAINTAIN YOUR NUTRITIONAL STATUS THROUGHOUT THE CHALLENGE?

S: No! I lost almost 4% of my body weight in one week and although I didn't do any 30

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anthropometry, I felt I lost muscle mass and strength as I was struggling with my normal weights at the gym. At my baseline I would always finish what was on my plate, however, on the pureed diet I struggled to finish most meals and never once went back for seconds. I was often left feeling physically full from the extra fluid, but not satiated. This has made me reflect on patient’s needs for food fortification advice and nutritional supplements, as it highlighted how difficult it can be to meet nutritional needs on a texture modified diet.

L: No, I didn’t weigh myself before or after,

but I wish I had! I felt like my clothes were looser and I was weaker. I went on a night out with friends and had no stamina. The meals left me feeling bloated and full, but then hungry again a short while later. It has certainly put into perspective the difficulties faced when on a puree diet and the importance of food fortification. I am now much more likely to consider supplementation earlier on for patients on a puree diet.

R: No, I lost approximately 3% of my body

weight during the week. I also felt more tired, very bloated and constantly hungry. I noticed a definite drop in my fruit consumption. Smoothies/fruit juices are a good way to ensure micronutrient requirements are met in addition to your diet – though of course make sure any pips or pulp are sieved out and that fluids are at the correct consistency for individual patients.

J: I maintained my weight, likely due to a

combination of daily puddings and fortified milkshakes. The fact that fruit stopped being an easy snack and required preparation meant I ate less of it and I'm sure that if this challenge had gone on longer, this would have become an issue and may have impacted upon both my micronutrient status and my fibre intake.

CONCLUSION

Since completing the puree challenge and raising a massive £1,000 for the MND association, we have all seen puree meals in a different light; we now have more empathy for patients on this diet and feel our advice is more practical having experienced it ourselves. We understand the difficulties maintaining nutritional status due to experiencing early satiety. Food fortification advice becomes a standard requirement and oral nutritional supplements are considered much sooner in assessments.

Having been regularly asked the question, “Have YOU tried this?”, patients are always surprised when the answer is, “yes”. We feel that their confidence in us has improved as a result. Experiencing social isolation is something that none of us envisaged and we would definitely consider pointing patients in the direction of dysphagia support groups on discharge. We feel the challenge has had a huge impact on our practice and look forward to our next experiment!

Table 1: A food diary of an average puree meal day

Breakfast

Mixed berries and apple (to be added to yoghurt and blended porridge)

Lunch

Ready meal tuna sandwich/homemade bean bake with peas and mash

Homemade lemon sponge

Evening meal

Ready meal omelette, sautéed potatoes and beans/homemade broccoli bake (before and after)

Ready meal jam sponge www.NHDmag.com May 2017 - Issue 124

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FOOD & DRINK

PHYTATES AND CEREALS Priya Tew Freelance Dietitian, running Dietitian UK, a dietetic and nutritional consultancy business

Priya runs Dietitian UK, a freelance dietetic service. She works with private patients, the media, brands, PR companies and is well known on social media.

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

Wholegrains are something we often encourage people to eat more of, as they are considered highly nutritious and packed with fibre. Delving deeper, these cereal foods are also phytate-rich. Phytates are known to inhibit the absorption of some minerals, which begs the question how much of the nutrition in wholegrains does the body actually absorb. But there are ways to help increase absorption and to decrease the phytate content. Phytates (chemical name: inositol 6 phosphate) are mainly found in cereals and legumes, but also in seeds and nuts. They serve as the storage of phosphorus and minerals for the plant.1 Around 80% of phytate in cereals is found in the aleurone layers and the rest in the germ; the endosperm is almost phytate-free.1 Phytates form insoluble complexes with the minerals zinc, calcium, iron and magnesium. Thus, when they are present in a food, the full amount of these nutrients will not be absorbed. Phytate also negatively affects the absorption of lipids and protein because phytic acid inhibits enzymes that we need to digest our food, such as pepsin, amylases and trypsin, so it affects the absorption of lipids and protein.2 THE BENEFITS OF PHYTATES

Largely talked about due to their antinutrient, inhibitory effect on mineral absorption, phytates may have some health benefits. There is some research showing antioxidant and anticancer effects, specifically for prostrate, colon and breast cancers.1,3 Phytates can also prevent renal stone formation and some positive effects have been seen on blood glucose.1 Phytates may play a role in reducing the risk of heart disease through their effect on reducing blood cholesterol levels.3 Once phytate levels become too high in a food, these beneficial effects stop and the phytates work as anti-nutrients.3

The daily intake of phytate is estimated to be 0.3-2.6g/d in a Western diet, with a range of 504-844mg/d in the UK.1 It is obviously at the higher end in vegetarian diets. Vegetarians/vegans depend on many foods that are high in phytates for their iron and zinc, so the potential absorption issues that occur with phytates are especially of concern for them. There could also be a risk for infants who are weaned predominantly on cereals. After four months, infants have a reduced amount of minerals such iron in their body stores and breastmilk only provides low levels. If cereals are the main food intake it could potentially leave them deficient.2 CONTENT OF PHYTATES IN CEREALS

The amount of phytates in cereals varies due to differences in the variety of the cereal grown, the climate and environment, the stages of seed maturation and the method used to determine the phytate.3 DIGESTION OF PHYTATES

During digestion, phytase, found in plant foods, breaks down 37-66% of phytate to phytic acid in the stomach and small intestine.1 Phytic acid binds to minerals - iron, zinc and calcium - forming mineral complexes so the minerals cannot then be absorbed. Phytase can be inactivated by cooking and some processing methods, but even then some phytase is available in the gut from microbes in the large intestine and so is still able to degrade phytate.3 www.NHDmag.com May 2017 - Issue 124

FOOD & DRINK Phytic acid g/100g Maize Maize germ Wheat

0.72-2.22 6.39 0.39-1.35

Wheat bran

2.1-7.3

Wheat germ

1.14-3.91

Rice

0.06-1.08

Barley

0.38-1.16

Sorghum

0.57-3.35

Oats

0.42-1.16

Rye

0.54-1.46

Millet

0.18-1.67

Triticale

0.50-1.89

Wild rice

2.20

Quinoa

0.541

Some substances compete with phytic acid in the mineral binding process, they include organic acids, protein, peptides, beta-carotene and ascorbic acid. Eating these with phytates will, therefore, help increase the absorption of minerals. For example, ascorbic acid prevents the oxidation of ferrous to ferric iron which stops the iron-phytate complexes forming.3 Encouraging people to have a glass of juice, add vegetables, or cook with lemon/lime juice are some easy strategies. Hithamani and Srinivasan found that cooking millet with some lime juice increased the accessibility of polyphenols from grains by 25%.4 REDUCING THE PHYTATE CONTENT OF GRAINS

During food processing, preparation, storage and digestive phytate can be hydrolysed to other forms of inositol phosphate with fewer phosphate groups (lower inositol phosphates). These do not form mineral complexes and so do not have the same effect on mineral bioavailability.1,3 There has been a focus on reducing the phytates in foods before they enter the gut, so that the mineral-phytate complexes do not form. Phytase is extracted from plant foods (wheat bran) and soaking, malting, germination, fermentation and bread making is used to reduce the phytate in foods. To soak grains in order to help breakdown phytates, use one cup of grain in one cup of warm water with one to 34

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Table 1: The content of phytic acid in different cereal grain (adapted from ref 1)

two tablespoons of yoghurt and leave it for at least seven hours, or overnight. Milling can also reduce the phytate content of grains up to 90%, especially when the phytate is contained in the outer layer of the seed. However, this will also lead to other nutrient losses too. Malting is when a grain is allowed to sprout and then quickly dried. This process has been found to decrease phytic acid by 45%.5 Sprouting can increase the levels of phytase, which will then have more action on reducing phytate levels; this varies across cereals. The activity of phytase increases up to 11 times when sprouted. Bartnik and Szafranska found that with wheat, rye and oats, levels of phytase increased 4.5, 2.5 and nine times with soaking and sprouting and the phytate content in these same grains was reduced by 16% in barley, 30% in wheat and rye and 17% in oats.6 Grinding and two-hour soaking of wheat, rye and barley can reduce all the phytate in these grains. Soaking and sprouting of quinoa have been shown to reduce the phytate content by up to 98%.7 Degradation of phytate occurs at different stages of bread making. Decreasing the pH in the bread dough results in phytate breakdown, so sourdough reduces phytate more than yeast fermentation. The longer the fermentation, the more phytate is degraded; one study found that phytic acid was 99% degraded in rye bread with

Adding phytase immediately before a food is consumed has been shown to increase the absorption of some minerals, including zinc. However, this is not going to be something the general public can do. a long fermentation time and 82% degraded in a mix of 50/50 rye and wholegrain.8 So, the choice of bread can be a factor; choosing sourdough or fermenting for longer can reduce phytate levels. Adding phytase immediately before a food is consumed has been shown to increase the absorption of some minerals, including zinc. However, this is not going to be something the general public can do.9 Another option, but only possibly on a larger scale, is using a soil zinc application, or spraying the foliage of crops with zinc. This has been found to increase the zinc concentration and bioavailability in raw and cooked grains.10 SUMMARY

Phytates do decrease the minerals absorbed in grains, but this is not something that would normally be of concern in a meat-eating person with a well-balanced diet. For vegetarians,

vegans and those with a high amount of cereal grains in their diet, it could be worth thinking about some methods to improve the availability of minerals. Infant weaning should not just be carried out using cereals, but a range of foods including a more vegetable focused approach. Adding ascorbic acid to a meal with cereal grains in it will help improve the iron absorption, so simple advice around adding fruit and vegetables to a meal can make a difference. Soaking grains can help breakdown phytates, but may not be feasible for everyone. Eating sourdough bread or bread with a longer fermentation time will help reduce phytate levels too. Fortified foods are of course a good option and an easy one. Looking at a comparison of bioavailability of iron in a foods, fortified cereals with ascorbic acid score well.11 So, a fortified breakfast cereal with fruit and a glass of juice is a winning combination.

References 1 Schlemmer U, Frølich W, Prieto RM, Grases F. Phytate in foods and significance for humans: food sources, intake, processing, bioavailability, protective role and analysis. Mol Nutr Food Res. 2009 Sep [cited 2012 Feb 27]; 53 (Suppl2): S330-75. Abstract available from: www.ncbi.nlm.nih.gov/ pubmed/19774556 2 Abdoulaye Coulibaly, Brou Kouakou and Jie Chen (2011). Phytic acid in cereal grains: structure, healthy or harmful ways to reduce phytic acid in cereal grains and their effects on nutritional quality. American Journal of Plant Nutrition and Fertilization Technology, 1: 1-22. URL: http://scialert.net/ abstract/?doi=ajpnft.2011.1.22 3 Penn Nutrition: Vegetarianism. www.pennutrition.com/KnowledgePathway.aspx?kpid=2709&trid=19294&trcatid=38 4 Hithamani G and Srinivasan K (2017). Bioaccessibility of polyphenols from selected cereal grains and legumes as influenced by food acidulants. J Sci Food Agric, 97: 621-628. doi:10.1002/jsfa.7776 5 Hejazi SN1, Orsat VJ (2016). Malting process optimisation for protein digestibility enhancement in finger millet grain. Food Sci Technol 2016, Apr; 53(4): 1929-38. doi: 10.1007/s13197-016-2188-x. Epub 2016 Apr 18 6 Bartnik M, Szafranska I. Changes in phytate content and phytase activity during the germination of some cereals. J Cereal Sci. 1987 [cited 2012 Mar 26]: 5:23-8. Abstract available from: www.sciencedirect.com/science/article/pii/S073352108780005X 7 Valencia S, Svanberg U, Sandberg AS, Ruales J. Processing of quinoa (Chenopodium quinoa, Willd): effects on in vitro iron availability and phytate hydrolysis. Int J Food Sci Nutr. 1999 May [cited 2012 Mar 26]; 50 (3):203-11. Abstract available from: www.ncbi.nlm.nih.gov/pubmed/10627836 8 Nielsen MM, Damstrup ML, Dahl Thomsen A, Rasmussen SK, Kjærsgård Rasmussen S, Hansen A. Phytase activity and degradation of phytic acid during rye bread making. Eur Food Res Technol. 2007 [cited 2012 Mar 26]: 225: 173-81. Abstract available from: www.springerlink.com/content/ ak65661n70k73410/ 9 Brnić M, Hurrell RF, Songré-Ouattara LT, Diawara B, Kalmogho-Zan A, Tapsoba C, Zeder C, Wegmüller R. Effect of phytase on zinc absorption from a millet-based porridge fed to young Burkinabe children. Eur J Clin Nutr. 2017 Jan;71(1):137-141. doi: 10.1038/ejcn.2016.199. Epub 2016 Oct 19 10 Poblaciones MJ, Rengel Z. Soil and foliar zinc biofortification in field pea (Pisum sativum L): Grain accumulation and bioavailability in raw and cooked grains. Food Chem. 2016 Dec 1; 212: 427-33. Doi: 10.1016/j.foodchem.2016.05.189. Epub 2016 Jun 3 11 Christides T, Amagloh FK, Coad J. Iron bioavailability and Provitamin A from sweet potato and cereal-based complementary foods. Foods. 2015 Sep 18; 4(3): 463-476. doi: 10.3390/foods4030463

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CONDITIONS & DISORDERS

ADULT KETOGENIC DIET THERAPY: WHAT WE KNOW THUS FAR Kit Kaalund Hansen Senior Specialist Adult Ketogenic Diet Therapy Dietitian, University College London Hospitals NHS Foundation Trust Kit works in the National Hospital for Neurology and Neurosurgery in Queen Square, where she set up and leads the first UK based NHS funded Adult Ketogenic Diet Therapy Dietetic Service for individuals with epilepsy.

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

‘Epilepsy is a brain disorder characterised by a persistent predisposition for the occurrence of epileptic seizures.’ ‘Seizures are transient occurrences of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.’1 The onset of epilepsy can occur at any age and the most common non-genetic causes of epilepsy are central nervous system infection, vascular disease, head trauma, congenital disorder, neoplasm, anoxia and drug and alcohol abuse.2 Approximately 50 million people are diagnosed with epilepsy worldwide, making it the fourth most common neurological disease globally.3 Around 70% of individuals respond and benefit from AEDs, leaving 30% with options of various drug combinations with either surgery, vagus nerve stimulation and/or homeopathic methods in the attempt to manage their epilepsy.3 Pharmacoresistant epilepsy in adults significantly impacts on quality of life as often the prospects for education, employment and independence are compromised. In view of this, adults can become socially isolated and dependent.4 It is, therefore, of increasing importance for adults to have the opportunity to access noninvasive treatment, such as ketogenic diet therapy (KDT), after two AEDs have failed, should they wish to, as per paediatric NICE guidelines.5 BACKGROUND TO KDT

Before anti-epileptic drugs, fasting was the first successful proposed therapy for managing epilepsy: “If there is no food to digest, more energy could be applied to recovering health.” (Bernarr Macfadden, 1899). In 1911, fasting as a treatment for epilepsy, resulted in seizure freedom in 90% of children and 50% of adults. However, once refeeding

commenced, seizures returned and the need for a sustainable treatment was realised.6 In 1921, with fasting as a precursor and ketones in mind, the ketogenic diet (KD) was developed in the hope that it would mimic starvation.7 In 1928, literature on the efficacy of KDT in teenagers and adults was published;28 56% of the individuals improved, 12% were seizure-free, while 32% showed no significant change.8 Based on these results and with the emergence of AEDs in 1938, it was concluded that the KD was not a significantly effective treatment for adults. It was rarely studied or advised again until the 1990s, when Charlie Abrahams caught the attention of the media and his dedicated parents founded the Charlie Foundation,27 which in turn funded several studies that led to the re-introduction of KDT.9 Several modifications of KDT have since been developed to aid palatability, sustainability and compliance and to meet the individual’s needs: classical, modified, low glycaemic index and medium chain triglyceride.9 The modified ketogenic diet (or Modified Atkins Diet) is based on ‘targets’ for carbohydrate and fat with the inclusion of moderate protein, but it does not require the restriction of fluids.10 Studies show that the overall adherence to KDT is 45%. 38% adherence to the classical and 56% to the modified diet. In addition, drop out levels are higher on the classical diet (10-88%) compared to that of the modified (063%).11,12 Ultimately, the modified, low www.NHDmag.com May 2017 - Issue 124

Despite the fact that the reduction of overall seizure frequency and seizure freedom is marginally higher in children, KDT can significantly improve quality of life in adults . . .

GI and MCT diets are easier to adhere to than the classical, mainly because they allow more carbohydrate and protein.12 Based on this, these are more widely used in adult KDT and therapists are advised to initiate modified KDT for adults. RESEARCH AND EVIDENCE

The evidence for the use of various KDTs in children with epilepsy is well established by many studies since its reintroduction in the 1990s.13-18 Research in adults is limited; however, it is not nonexistent and should be brought to the attention of those managing pharmacoresistant epilepsy. Sirven et al19 found that at eight months of following ketogenic diet therapy, 3/11 patients achieved 90%, 3/11 noted 50-89% and 1/11 showed <50% reduction in seizures. The rest discontinued the diet. Mosek et al20 carried out a study on nine adults where two patients remained on a diet at 12 weeks as they achieved a seizure reduction of >50%. The remainder discontinued diet due to lack of efficacy. Klein et al21 showed that 50% of patients achieved >50% seizure reduction, and 33% had >85% reduction. Lambrechts et al22 assessed the efficacy of classical and modified KD in adults. 26.6% of the patients achieved >50% seizure reduction in the first month of KDT. Interestingly, when looking at the efficacy between the classical and modified versions of KDT, Klein et al11 found no significant difference. 38

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More specifically, 32% from the classical group and 29% from the modified group, achieved >50% seizure reduction, while 9% and 5% respectively achieved >90% reduction. Kverneland et al23 examined the efficacy and tolerability of KDT as an adjuvant therapy to antiepileptic drugs for adult patients with pharmacoresistant generalised epilepsy; 13 patients were treated with a modified Atkins diet for 12 weeks. Six participants completed the 12-week trial and four had >50% seizure reduction with reduced seizure severity and improved quality of life. At present, all epilepsy types are trialled on KDT as it is not known what seizure types might respond best to therapy. Interestingly, all responders from the Kverneland study were diagnosed with juvenile myoclonic epilepsy. IMPROVED QUALITY OF LIFE

Despite the fact that the reduction of overall seizure frequency and seizure freedom is marginally higher in children, KDT can significantly improve quality of life in adults, which is often related to the fact that KDT helps to create a routine that focuses the mind, e.g. concentration and alertness, energy levels, relationships with family and friends, future outlook on life, hope and independence.22 Some might dismiss the efficacy of KDT in adults and focus on the adverse effects of KDT. However, it is important to emphasise that with regular monitoring and appropriate interventions, these side effects can be minimised and well managed.24,25 Yet, the rate of discontinuation remains approximately 50%. The challenge of changing an individualâ&#x20AC;&#x2122;s lifestyle cannot be underestimated, e.g. specific and rigid regimen, exclusion of some food preferences, economic cost, as well as the social cost, e.g. social eating, advance meal preparation etc, and lack of motivation, might account for poor compliance.

CONDITIONS & DISORDERS PREGNANCY

In addition to the above, and perhaps on a side note, therapists are facing further challenges in adulthood such as pregnancy. At present, it is not advised to fall pregnant whilst following KDT based on ketoacidosis evidence in diabetics. However, van der Louw et al26 reported on two case studies of pregnant women who were treated with: a) a classical KD with 47g-75g CHO restriction, supplemented with MCT with ketones of 0.4-1.2mmol/L and b) a modified KD with a 20g-30g CHO restriction in adjunction with Lamotrigine, with unspecified ‘low urine ketones’. Fetal and neonatal growth was normal for case study a), as was growth and development at 12 months. For case study b), the child was born with bilateral ear deformities of unknown significance, but the child’s neurodevelopment was reported to be normal at eight months.

Safety still needs to be established for nonpharmacological treatments in pregnancy; however, concerns are many and studies are ethically difficult to carry out. CONCLUSION

The lack of ample evidence on the efficacy of KDT on adult patients with refractory epilepsy and the importance of such treatment, makes it crucial to investigate further. In order to justify treatment to GPs, NICE guidelines are in desperate need, as adult dietitians are faced with GPs refusing to fund KDT often due to lack of knowledge on the matter. However, without guidelines, GPs are perfectly in their right to decline involvement in KDT. Adult and paediatric centres in the UK gathered in April for the first ketogenic research meeting to discuss future prospects, in the hope that KDT will eventually be readily available and recognised as a second line treatment for adult with drug-resistant epilepsy.

References 1 Fisher RS, van Emde Boas W, Blume W, Elger C, Genton P, Lee P and Engel J Jr (2005). Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia, 46, 470-2 2 Lindsay K, Bone I (1997). Neurology and Neurosurgery Illustrated. 3rd Ed. UK: Churchill Livingstone 3 World Health Organisation (WHO) (2016). Epilepsy [online] available at: www.who.int/mediacentre/factsheets/fs999/en/. [accessed 5 May 2016] 4 UCB Pharma (2008). Epilepsy and quality of life: fact sheet. available at: www.ucb.com/_up/ucb_com_news/documents/epilepsy_and_quality_of_life.pdf [accessed 17 May 2016] 5 National Institute for Health and Care Excellence (NICE) (2012). Epilepsies: diagnosis and management. 6 Wheless JW (2004). History and origin of the ketogenic diet. Epilepsy and the ketogenic diet. Springer 7 Schwartz RH, Eaton J, Bower BD and Aynsley-Green A (1989). Ketogenic diets in the treatment of epilepsy: short-term clinical effects. Dev Med Child Neurol, 31, 145-51 8 Barborka CJ (1928). Ketogenic diet treatment of epilepsy in adults. Journal of the American Medical Association, 91, 73-78 9 Wheless JW (2008). History of the ketogenic diet. Epilepsia, 49 suppl 8, 3-5 10 Kossoff EH and Dorward JL (2008). The Modified Atkins Diet. Epilepsia, 49 suppl 8, 37-41 11 Klein P, Tyrlikova I and Mathews GC (2014). Dietary treatment in adults with refractory epilepsy: a review. Neurology, 83, 1978-85 12 Payne NE, Cross JH, Sander JW and Sisodiya SM (2011). The ketogenic and related diets in adolescents and adults - a review. Epilepsia, 52, 1941-8 13 Henderson CB, Filloux FM, Alder SC, Lyon JL and Caplin DA (2006). Efficacy of the ketogenic diet as a treatment option for epilepsy: meta-analysis. J Child Neurol, 21, 193-8 14 Keene DL (2006). A systematic review of the use of the ketogenic diet in childhood epilepsy. Pediatr Neurol, 35, 1-5 15 Lefevre F and Aronson N (2000). Ketogenic diet for the treatment of refractory epilepsy in children: a systematic review of efficacy. Pediatrics, 105, e46 16 Pfeifer HH and Thiele EA (2005). Low-glycaemic-index treatment: a liberalised ketogenic diet for treatment of intractable epilepsy. Neurology, 65, 1810-2 17 Sharma S, Sankhyan N, Gulati S and Agarwala A (2013). Use of the Modified Atkins Diet for treatment of refractory childhood epilepsy: a randomised controlled trial. Epilepsia, 54, 481-6 18 Vining EP, Freeman JM, Ballaban-Gil K, Camfield CS, Camfield PR, Holmes GL, Shinnar S, Shuman R, Trevathan E and Wheless JW (1998). A multicentre study of the efficacy of the ketogenic diet. Arch Neurol, 55, 1433-7 19 Sirven J, Whedon B, Caplan D, Liporace J, Glosser D, O'Dwyer J and Sperling MR (1999). The ketogenic diet for intractable epilepsy in adults: preliminary results. Epilepsia, 40, 1721-6 20 Mosek A, Natour H, Neufeld MY, Shiff Y and Vaisman N (2009). Ketogenic diet treatment in adults with refractory epilepsy: a prospective pilot study. Seizure, 18, 30-3 21 Klein P, Janousek J, Barber A and Weissberger R (2010). Ketogenic diet treatment in adults with refractory epilepsy. Epilepsy Behav, 19, 575-9 22 Lambrechts DA, Wielders LH, Aldenkamp AP, Kessels FG, de Kinderen RJ and Majoie MJ (2012).The ketogenic diet as a treatment option in adults with chronic refractory epilepsy: efficacy and tolerability in clinical practice. Epilepsy Behav, 23, 310-4 23 Kverneland M, Selmer KK, Nakken Ko, Iversen PO, Tauboll E (2015). A prospective study of the Modified Atkins Diet for adults with idiopathic generalised epilepsy. Epilepsy Behav. 53: 197-201 24 Winesett SP, Bessone SK and Kossoff EH (2015). The ketogenic diet in pharmacoresistant childhood epilepsy. Expert Rev Neurother, 15, 621-8 25 Schoeler NE and Cross JH (2016). Ketogenic dietary therapies in adults with epilepsy: a practical guide. Pract Neurol, 16, 208-14 26 van der Louw EJ, Williams TJ, Henry-Barron BJ, Olieman JF, Duvekot JJ, Vermeulen MJ, Bannink N, Williams M, Neuteboom RF, Kossoff EH, Catsman-Berrevoets CE, Cervenka MC (2017). Ketogenic diet therapy for epilepsy during pregnancy: a case series. Seizure, 45: 198-201 27 The Charlie Foundation (2014). Classic ketogenic and modified ketogenic. The Charlie Foundation for Ketogenic Therapies. available at: www.charliefoundation.org/ explore-ketogenic-diet/explore-2/classic-ketogenic [accessed 3 may 2016] 28 Helmholz HF (1927). The treatment of epilepsy in childhood: five years' experience with the ketogenic diet. Journal of the American Medical Association, 88, 2028-2032

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SKILLS AND LEARNING

Nikki Brierley Specialist Dietitian and CBT Therapist

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

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

MINDFULNESS AND NUTRITION Mindfulness is now a commonly used term and is a widely accepted method of dealing with the stresses and challenges of daily life. It also has the potential to reduce ‘mindless eating’ and positively affect eating behaviours and nutritional status. Mindfulness is a simple process; nevertheless, it can be difficult to define and there are many differing opinions about how it is best achieved and what purpose it serves. It is, however, accepted that mindfulness involves deliberately focusing attention on the present experience, in a non-judgemental manner and that this results in a state where there is an increased awareness of the emotional, mental and physical sensations being experienced in the moment.1 Figure 1 provides a simple overview of mindfulness in the form of a diagram. With a rich history, mindfulness appears to have originated and developed in Hindu and Buddhist traditions. However, following a specific religion is not a requirement of practicing

Figure 1: What is mindfulness?

Source: www.getselfhelp.co.uk/mindfulness.htm

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mindfulness and the process does not conflict with faith or scientific beliefs. The popularity of mindfulness in Western society, greatly increased after Jon KabatZinn recognised and researched the potential benefits in the clinical setting. There is now a large body of evidence that demonstrates the effectiveness of mindfulness in reducing psychological distress across a variety of conditions.1 THE POTENTIAL BENEFITS

The benefits of mindfulness are generally described as ‘conscious living’, in that the practice of mindfulness can allow individuals to detach from their thoughts and connect with the observing self (i.e. the part that is aware of, but separate from the thinking self). Learning and

Figure 2: Mindless eating

Thought I have so much to do, how am I going to get it done?

Physical Sensation Knot in stomach and tense

Emotion Apprehension and fear

Behaviour Automatic response = Eat comforting food

applying these skills can help individuals to live in a manner that is consistent with their personal values and to develop psychological flexibility.1 Mindfulness most certainly isnâ&#x20AC;&#x2122;t the answer to everything, although it is increasingly used within psychological services as part of therapy for a variety of different mental health concerns. In addition, there is strong evidence for the value of regular practice on overall health and wellbeing.2 As mindfulness helps with recognising emotions and the negative methods that are used to control and suppress feelings/urges, it

is easy to see the possible benefit of applying this approach to nutritional intake in order to reduce â&#x20AC;&#x2DC;mindlessâ&#x20AC;&#x2122; eating. Mindless eating can be described as eating on automatic pilot, with little or no conscious awareness of choice. Figures 2 and 3 demonstrate an example of the potential differences between mindless and mindful eating. The cultivation of moment-to-moment awareness can help to create a calmer and more assertive approach to eating behaviours and thus may provide the space to recognise unhelpful and self-limiting patterns.

Figure 3: Mindful eating

Thought I am having the thought "I have so much to do, how am I going to get it done?"

Emotion I am aware I am feeling apprehension and fear

Physical Sensation I am experiencing a knot in stomach and feel tense

Behaviour Practice mindfulness = Acknowledge thoughts and feelings, choose not to eat at this moment

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SKILLS AND LEARNING Table 1: Eating mindfully Slow down the pace. Eat without distractions. Become aware of hunger and fullness signals and use them to guide decisions. Acknowledge and observe the response to food in a non-judgemental manner. Choose foods that are both enjoyable and nutritional. Reflect on experience of mindless eating. Introduce mindfulness as part of daily activities. Source: Adapted from Susan Albers (2009)4

MINDFULNESS TECHNIQUES

The best way to understand mindfulness is to practice and experience it on a regular basis. There is a wealth of training providers available, with resources in the form of books, CDs, weekly classes, workshops and retreats. It is important to remember that the fundamental factor is to deliberately focus on the present experience, in a non-judgemental manner. The aim is not to ‘empty the mind’ or ‘ignore thoughts’, instead it is to become aware of the here and now and to simply observe anything that arises during the practice. There are various methods to introduce the practice and different options suit different people. There are also specific mindful eating exercises that involve focusing on the consumption of food items in a slow and deliberate manner. Commonly used items include chocolate and raisins, however any suitable small food can be chosen. The aim of the exercises is to learn to engage with the food that is being eaten, to notice the appearance of the food, the textures and smells and to recognise how the body and mind react to the eating process. Some of the most common exercises are briefly described opposite and these are often referred to as formal practice. INTEGRATING MINDFULNESS

The exercises described in this article can be extremely useful and an excellent introduction to mindfulness. It is, however, also recommended

that mindfulness is incorporated into everyday daily activities (i.e. making/drinking a cup of tea, brushing teeth, walking etc), and that generally, on a day-to-day/moment-to-moment basis, there is an increased awareness of thoughts, feeling, sensations and surroundings. With regards to eating, again completing a mindful eating exercise can be an ideal starting point. It is, nevertheless, acknowledged that eating a small quantity of food in such a slow and deliberate manner may not be possible or desirable in everyday circumstances. Instead, it is suggested that general mindfulness approach is adapted as described in Table 1. SUMMARY

Mindfulness involves deliberately focusing on the present, in a non-judgemental manner, the results of which include increased awareness of the emotional, mental and physical sensations that are being experienced in the moment. This can develop a connection to the observing self and thus give rise to ‘conscious living’. As such, in its very nature, mindfulness has the potential to help individuals make nutritional decisions that are not based on emotional or habitual patterns (i.e. mindless eating). By teaching the skills of bringing awareness to the present moment, in a non-judgemental manner, the chances of eating in line with values and goals may be greatly increased. Therefore, mindfulness may be an important approach to include when recommending nutritional changes.

References 1 Jon Kabat-Zinn (2014). Wherever you go there you are - Mindfulness meditations for everyday life 2 www.nhs.uk/conditions/stress-anxiety-depression/pages/mindfulness.aspx 3 Breath Works Mindfulness for Stress, A Four Session Course. www.breathworks-mindfulness.org.uk/ 4 Susan Albers (2009) Eat, drink and be mindful

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MINDFULNESS EXERCISES 1 Breath meditation/breathing exercise This can be practiced sitting, standing or lying down and can be done for 1+ minutes: •

Begin by noticing the breath, being aware of the breathing in and out.

•

Without trying to change the breath, notice what is happening in the body and feel the breath (i.e. slowly move focus of what happens in the rib cage, the stomach, the abdomen, the lower, middle and upper back, the shoulders, the nose, the lips and the throat).

•

Notice the rhythm of the breath and how it changes.

•

As thoughts arise, notice any thoughts and then bring the awareness back to the breath.

•

Finish the practice and bring the awareness back to the surroundings.

2 Body scan This is commonly practiced lying down and lasts between 10-20 minutes: • Begin by bringing the awareness to the belly and how it rises and falls with the breath. •

Move the awareness to solar plexus and then to the chest.

•

Take the awareness to the lower back, be aware of the subtle movement with the breath.

•

Move the awareness to the middle and then upper back, then the shoulders, noticing again the subtle movement with the breath.

•

Be aware of the whole of the torso and the breath.

•

Bring awareness to the upper arms, then the lower arms, moving to the hands, then fingers and then thumbs.

•

When the mind wonders gently bring the focus back to the body.

•

Transfer the awareness to the shoulders, moving to the back of neck and throat, noticing the breath.

•

Bring the awareness to the head, the back of the head and then the face.

•

Explore the sensation of the face, cheeks, nose, and lips.

•

Move the focus to the tongue, jaw, ears, eyes, forehead and then the scalp.

•

Bring the awareness back the belly and notice again the movement with the breath.

•

Move awareness to the buttocks, hips, pelvic floor, upper legs and then the thighs.

•

Moving then to the knees, lower legs, ankles, feet, soles and top of feet and then the toes.

•

Expand the awareness to the whole body and the breath.

•

Notice how the body moves with the breath.

•

Finish the practice and bring the awareness back to the surroundings.

3 Mindful movement This is practised standing, or can be adapted to seated or lying, generally lasts 1-20 minutes: •

Follow the sequence of movements and breathing whilst inhabiting the body.

•

Begin by standing with the feet hip distance apart and knees soft, shoulders relaxed and arms hanging by sides.

•

Feel the contact between the feet and the floor.

•

Notice and tune into the breath, beware of the breath in and out.

•

Aim to move in time with the breath (avoid changing the breath to the movement).

•

Gently turn from the waist, allowing the arms to be lose, move mainly from the hips.

•

Gently stop and return to the start position.

•

Lift arms to shoulder height, rotate the arms to face the ceiling, lift hands towards the ceiling/sky.

•

Lower hands to shoulder height and rotate hand back to the floor and slowly lower the hands.

•

Return to the starting position (resting in standing).

•

Repeat above one arm at a time, right followed by left.

•

Notice the sensations of the body and check in with experience.

•

When the mind wonders gently bring the focus back to the movement and the breath.

(Source: Adapted from Breath Works3)

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BDA: RESEARCH

BDA: SUPPORTINGTHE LATEST DIETETIC RESEARCH www.bda.uk.com

The annual BDA Research Symposium is a highlight event in the dietetic calendar and is a fantastic opportunity for dietitians to showcase their latest research. Over the last few years, the Symposium has soared in popularity and has grown to include dietitians from all areas of the profession including dietetic students, dietitians working in clinical practice, public health dietitians and research dietitians. Research presented at the Symposium could be anything from an undergraduate dissertation, an MSc/MRes project, a PhD study via a university or sponsored by the National Institute for Health Research (NIHR)/Health Education England (HEE), or practice-based research in a dietetic setting. The supportive environment makes it an encouraging and exciting place to present, network, collaborate, learn, and promote dietetics! Itâ&#x20AC;&#x2122;s also a great place to share best practice, new interventions and stimulate interest in research. HOW DOES THE SYMPOSIUM WORK?

There is a call for abstracts several months before the event which takes place every December in Birmingham. Abstracts are reviewed and judged anonymously, then sent back to the applicant with feedback. The applicant can then choose whether to re-submit their abstract for presentation once the feedback has been incorporated. ATTENDING ON THE DAY

A range of presenters each have seven minutes to present their research. In addition to these presentations, attendees can listen to two inspiring 44

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presentations from long-standing BDA members and specialised dietitians on a topic that has impacted or shaped dietetic practice. Attendees are also able to browse the exhibition space, which includes a range of BDA partners and an area to speak with expert BDA staff who are on hand to provide advice, guidance and a range of useful resources to help in your practice. LOOKING BACK AT 2016

The 2016 BDA Symposium got off to a flying start, with BDA member Professor Mary Hickson presenting her latest research undertaken for the Future Dietitian 2025 project Future Dietetic Workforce - working towards a new strategy. This was followed by BDA member Yvonne McKenzie presenting her work with the BDA Gastroenterology Specialist Group on their updated practice guidelines for the management of irritable bowel syndrome. Delegates enjoyed a breadth of interesting topics throughout the day with six main streams including Clinical Nutrition, Public Health, New

to Research, Paediatrics, Service Evaluation and Sport and Exercise Nutrition. Research on a variety of topics was presented from diabetes and HIV, clinical caseload, parenteral and enteral nutrition, effectiveness of dietetic interventions and many more areas. Of course, the Symposium always ensures a delicious and nutritious selection of lunch and snacks too! Due to popular demand, 2016 also saw the first Satellite Symposium in Northern Ireland. Fourteen abstracts were presented alongside BDA member Dr Caomham Logue’s presentation on assessing intakes of lowcalorie sweeteners, and BDA member Dr Paula McGurk’s presentation on self-screening for nutritional risk in hospital outpatients using an electronic system. ATTEND THE 2017 SYMPOSIUM

If you’re working in, undertaking, or interested in dietetic research, then attending the BDA

Research Symposium or submitting an abstract is well worth your time. Find out more about what’s in store for the 2017 Symposium and book your place to attend. BDA members can enjoy a reduced rate to attend too. GET PUBLISHED!

The Journal of Human Nutrition and Dietetics (JHND) is the BDA’s international peerreviewed journal that provides the latest research, reviews, practice guidelines and discussion papers in the field of nutrition and dietetics. JHND has a high performing impact factor and is consistently ranked as one of the most valued benefits by BDA members, as full access to published articles is part of BDA membership. All abstracts presented at the BDA Research Symposium are published in JHND and are arranged according to the six streams.

JOIN THE BDA The BDA aims to support evidence-based practice for dietitians by making the latest research as accessible as possible. A highly valued benefit of becoming a BDA member is free access to the Practice-based Evidence in Nutrition (PEN) system. PEN is an invaluable resource which condenses and summarises the entire nutrition and dietetic evidence base on more than 190 nutrition- and dietetic-related topics, then gives you practical guidance to help apply this to dietetic practice. Why not speak to a colleague who is a member and consider joining us? We also invite you to take a look at the full list of membership benefits.

www.bda.uk.com/join www.NHDmag.com May 2017 - Issue 124

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. She has been a columnist on nutrition for more than 30 years.

Ursula meets amazing people who influence nutrition policies and practices in the UK. DURWIN BANKS Linseed Farmer; West Sussex Owner; The Linseed Farm brand of culinary oils Member; Brighton and Sussex University Food Network

Attending Nutrition Society conferences is the best way to keep up-to-date with research aspects of nutrition science. And to meet lots of interesting nutritionists and dietitians - and biochemists, physiologists, epidemiologists, policy experts - and farmers? Which is how and where I met Durwin Banks (Nutrition Society winter conference, December 2016). Durwin shares the ownership of a linseed farm with his sisters and has become a champion for this product. He produces linseed oil* on site to match mail-order demand, and does much to promote and market this special superfood. “I know that lots of foods are described as ‘superfoods’, but linseed oil really does provide uniquely high amounts of omega-3 fatty acids,” says Durwin. Perhaps because culinary linseed oil is such a specialist food, Durwin has had to become nutritioninterested, beyond just growing the stuff. He left school at a young age, and worked on the responsibilities of supporting his father on the family farm. There were good times and bad times, but days were always long and work was always hard, with dairy, beef, chickens and sheep, along with some arable projects. Linseeds were first grown on the farm as a break-crop, to support soil quality after more nutrient-depleting crops, and were not considered of much value in themselves, beyond being a base ingredient for animal feed and oils for floors and wood.

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Durwin tells me that he has had many make-a-million ideas (I feel the eyerolling around the Banks’ dinner table, as the next get-rich plan is hatched). He grew four acres of chamomile flowers and made a still to produce finest distilled oil. But the project would take longer and need more land than planned to become profitable, and the buyer of his still invited him over to show him his hemp oil press. This sparked the idea of culinary linseed oil production. Linseeds are planted in spring and in early autumn; when the fields are full of beautiful pale lilac flowers, the crop is ready for harvesting. Each pod of the plant contains eight to 10 brown or golden seeds (depending on the plant variety). There is a small market for whole seeds, but after cleaning and drying, most seeds are crushed to produce high quality oil for human consumption. The production unit on Durwin’s farm produces about 180 litres daily, although this is made to match demand so that it is always fresh. The bottles are labelled with a press date, with advice to keep refrigerated and to be consumed within two months. Any leftover oils or crushed oil cake is sold to farmers as cattle or equine feed, so there is never any waste. Growing plants is what farmers do and making processed product on-site is the next step in allowing farmers greater income and greater control. But marketing a food with unique nutritional features of linseed oil, is quite the challenge.

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 Linseeds are popular as an addition to cereals and breads, as a way to boost fibre content. “They produce a gummy gel when moist, which helps digestion,” says Durwin. Brown and gold seeds are identical nutritionally, but he is excited to be planting a gold seed variety this year called ‘marmalade’ (“I will walk through fields of marmalade”). But linseed oil is the star product. It is not heat stable, so can be used in dressings or drinks, or stirred into hot cooked foods. However, it cannot be used for frying or cooking. “I have regular food analysis done on linseed oil samples and results always show alpha linolenic acid (ALA) levels of about 60%: this is six-fold the amounts in soya or rapeseed oil, and most other vegetable oils have none.” But ALA does not have the potency of the pre-formed long-chain omega-3’s found in fish, I probe. “Well studies do show some conversion in the body, and there is a lot of agreement that omega-3 to omega-6 ratios in the diet should be increased. And also, fish are in short supply and not everyone likes fish,” is the well-practiced response from Durwin. Indeed, vegans and vegetarians looking for plant-sourced omega-3s are a large part of his mail-order customer base. Along with people with psoriasis and other skin conditions, pregnant women, people anxious to delay dementia conditions, as omega-3s are suggested to support cognition, and a small tail of people with cancer following the ‘Budwig diet’. Durwin holds many farm open days, and also attends many consumer exhibitions themed on health and diet. He has a website and a youtube channel. “But most orders seem to be via wordof-mouth, so orders can be very variable,” says Durwin.

“Most farmers do not realise the role they should be playing to keep people healthy.” He is clearly a man on a mission with the double audience of fellow farmers and healthinterested consumers. He feels strongly that the skills of farmers are not valued, and that the pressures to fit into systems controlled by large companies and retailers often crush them. He was an invited speaker at the Oxford Real Farming conference in February 2017, which supports sustainable and organic farming practices, and predicts that soil quality will be the next ‘crisis’ issue. Other than being a farmer and attending occasional Nutrition Society meetings, Durwin likes to keep busy. For many years he was a parish councillor and is an active member of the Brighton and Hove Food Partnership. After a busy day farming, he has a busy evening sitting at the computer. “I am writing a book,” states Durwin, “with the title: The Farmer Will See You Now - your prescription for a healthy life doesn’t come from the chemist, but from the farmer.” He hopes it will be out in December, in time for the Christmas gifting season. While Durwin is not a scientist, he knows more about nutrition than I will ever know about farming and his solo dedication at promoting such a specialist nutritional product is impressive. I am ready to leave and he puts his hat on. Just as I am thinking, ‘hats off.’

*Declaration of bias: I have grown up with linseed oil so it is hash-tagged onto my mental list of comfort foods; lovely sloshed onto potatoes or soup, or as a bread-dip. This is due to my fathers’ upbringing in former East Germany, where food variety and quality was consistently poor. Potatoes with linseed oil and quark (smooth curd cheese) were always available and affordable and the best way to battle hunger. Ursula www.NHDmag.com May 2017 - Issue 124

ONLINE RESOURCES

WEB WATCH Useful information, research and updates. Visit www.NHDmag.com for full listings. COCHRANE DATABASE OF SYSTEMATIC REVIEWS EFFECTS OF LOW SODIUM DIET VERSUS HIGH SODIUM DIET ON BLOOD PRESSURE, RENIN, ALDOSTERONE, CATECHOLAMINES, CHOLESTEROL AND TRIGLYCERIDE Niels Albert Graudal, Thorbjorn Hubeck-Graudal, Gesche Jurgen. Editorial Group: Cochrane Hypertension Group. First published 9th April 2017. ‘In spite of more than 100 years of investigations, the question of whether a reduced sodium intake improves health is still unsolved.’ The review objectives: To estimate the effects of low sodium intake versus high sodium intake on systolic and diastolic blood pressure (SBP and DBP), plasma or serum levels of renin, aldosterone, catecholamines, cholesterol, highdensity lipoprotein (HDL), low-density lipoprotein (LDL) and triglycerides. A total of 185 studies were included. The average sodium intake was reduced from 201mmol/day (corresponding to high usual level) to 66mmol/day (corresponding to the recommended level). The author’s conclusions: Sodium reduction from an average high usual sodium intake level (201mmol/day) to an average level of 66mmol/day, which is below the recommended upper level of 100mmol/day (5.8g salt), resulted in a decrease in SBP/DBP of 1/0mmHg in white participants with normotension and a decrease in SBP/DBP of 5.5/2.9mmHg in white participants with hypertension. A few studies showed that these effects in black and Asian populations were greater. The effects on hormones and lipids were similar in people with normotension and hypertension. Renin increased 1.60ng/mL/hour (55%); aldosterone increased 97.81pg/mL (127%); adrenalin increased 7.55pg/mL (14%); noradrenalin increased 63.56pg/mL: (27%); cholesterol increased 5.59mg/dL (2.9%); triglyceride increased 7.04mg/dL (6.3%). Full more details at: www.onlinelibrary.wiley.com/ doi/10.1002/14651858.CD004022.pub4/full

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INFANT FORMULAS CONTAINING HYDROLYSED PROTEIN FOR PREVENTION OF ALLERGIC DISEASE AND FOOD ALLERGY David A Osborn, John KH Sinn, Lisa J Jones. Editorial Group: Cochrane Neonatal Group First published 15th March 2017. ‘Allergy is common and may be associated with foods, including cows’ milk formula (CMF). Formulas containing hydrolysed proteins have been used to treat infants with allergy. However, it is unclear whether hydrolysed formulas can be advocated for prevention of allergy in infants.’ The review objectives ‘To compare effects on allergy and food allergy when infants are fed a hydrolysed formula versus CMF or human breast milk. If hydrolysed formulas are effective, to determine what type of hydrolysed formula is most effective, including extensively or partially hydrolysed formula (EHF/PHF). To determine which infants at low or high risk of allergy and which infants receiving early, short-term or prolonged formula feeding may benefit from hydrolysed formulas.’ ‘Two studies assessed the effect of three to four days' infant supplementation with an EHF whilst in hospital after birth versus pasteurised human milk feed. Results showed no difference in infant allergy or childhood cows’ milk allergy (CMA). No eligible trials compared prolonged hydrolysed formula versus human milk feeding. The author’s 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. Find the full review at http://onlinelibrary.wiley. com/doi/10.1002/14651858.CD003664.pub4/full

COCHRANE LIBRARY SPECIAL COLLECTION - ENABLING BREASTFEEDING This Cochrane Special Collection of systematic reviews on Breastfeeding has been developed to bring the best available evidence on effective care to the attention of decision makers, health professionals, advocacy groups and women and families, and to support the implementation of evidence-informed policy and practice. The collection focuses on reviews on support and care for breastfeeding women, including treatment of breastfeeding associated problems; health promotion and an enabling environment; and breastfeeding babies with additional needs. It includes: • Support for breastfeeding women - building skills and confidence whilst breastfeeding. • Health promotion and enabling environment - the promotion of breastfeeding, public policies to protect breastfeeding women in the workplace, and the education and training of staff. • Care for breastfeeding women and their babies - to ensure that routines in care promote and optimise the normal physiological processes of milk production and release. Also to inform best practice and identify harmful practices. • Treatment of breastfeeding problems. Many problems can be prevented with good quality care, but when they do occur, it is important that evidence-informed skilled care is available. • Feeding practices for preterm babies/babies with additional needs and their mothers. Breastfeeding is especially important for babies born too soon or too small or who are sick, yet the use of breastmilk substitutes is common for these vulnerable babies. Particular challenges for these babies and their mothers include separation when they are cared for in incubators and the baby’s immature development and problems with suck/swallow coordination, as well as the frequent use of breastmilk substitutes in neonatal units. Some reviews in this section concern feeding practices for all preterm babies and are not specific to breastfeeding. Available at: www.cochranelibrary.com/app/content/special-collections/article/?doi=10.1002/14651858.10100214651858

NICE GUIDELINES IRRITABLE BOWEL SYNDROME IN ADULTS: DIAGNOSIS AND MANAGEMENT (CG61) Published February 2008. Updated April 2017. This guideline covers diagnosing and managing irritable bowel syndrome (IBS) in people aged 18 and over. It details how to accurately diagnose IBS, and aims to improve the quality of life for adults with IBS by promoting effective management using dietary and lifestyle advice, pharmacological therapy and referral for psychological interventions. In April 2017, recommendation 1.1.1.2 was updated in line with more recent guidance on recognition and referral for suspected cancer. This recommendation is dated 2017. Recommendation 1.1.1.3 was removed as it was no longer needed after the changes to recommendation 1.1.1.2. This guideline includes recommendations on diagnosing IBS, dietary and lifestyle advice, pharmacological therapy, referral for psychological interventions and follow-up. Find more information at: www.nice.org.uk/guidance/CG61

ALCOHOL-USE DISORDERS: DIAGNOSIS AND MANAGEMENT OF PHYSICAL COMPLICATIONS (CG100) Published June 2010. Updated April 2017. This guideline covers care for adults and young people (aged 10 years and older) with physical health problems that are completely, or partly, caused by an alcohol-use disorder. It aims to improve the health of people with alcohol-use disorders by providing recommendations on managing acute alcohol withdrawal and treating alcohol-related conditions. This guideline includes recommendations on acute alcohol withdrawal, Wernicke’s encephalopathy, alcohol-related liver disease and alcohol-related pancreatitis. Full details can be found at: www.nice.org.uk/guidance/cg100

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DATES FOR YOUR DIARY UNIVERSITY OF NOTTINGHAM SCHOOL OF BIOSCIENCES Modules for Dietitians and other Healthcare Professionals • Obesity Management (D24BD3) 3rd/4th October, 5th/6th December

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

• Gastroenterology (D24GE1) 10th/11th October, 12th/13th December

For further details please contact 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'.

Coming up soon . . .

Coeliac UK Awareness Week 8th to 14th May www.Coeliac.org.uk European Congress on Obesity 17th to 20th May Porto, Portugal www.eco2017.easo.org/

NICE annual conference 18th to 19th May ACC Liverpool www.niceconference.org.uk/

Wednesday 17th May OR Thursday 7th December 2017 Cost: £120 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

Suitable for those new to Ketogenic therapy or wanting to update and network with other Keto teams. 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 SENIOR I - GIBRALTAR £36,970 to £44,149 pa (depending on experience). Relocation assistance provided. Now is your opportunity to sample the Mediterranean way of life. We are looking for an enthusiastic, experienced and highly motivated Senior I Dietitian, with a broadbased background in general Dietetics. The successful candidate should have recent paediatric experience and will be tasked with a varied caseload including acute (medical /surgical) wards, long stay wards and general outpatient clinics, as well as providing training/ education for nursing staff as required. If you would like to discuss any aspects of the post, please contact Ms Melanie McLeod, Senior Dietitian on Tel: 00350 20072266 ext 2199 or email: melanie.mcleod@gha.gi; Application Packs are obtainable from the Recruitment Section on ext 2081. Email: hr@gha.gi. Closing Date: 8th May 2017

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WATERFALL DIETITIAN - S ENGLAND & LONDON £30 to £35K dependent on experience and qualifications. Full-time permanent position. Travel required. 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 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 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. To apply please send CV and covering letter to rosanna@ gartonhardy.com. Closing Date: 12th May 2017

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.

For the last few years, some of the ‘Senior’ Fellows of the BDA have arranged to meet up for lunch. This year we met at a restaurant close to King’s Cross in London. As I was coming down for the day, I had also arranged to see Ursula Arens, a longstanding friend and writer for NHD. Prior to the lunch meeting we had decided to discuss the BDA, particularly in the light of there being no quorum at the last AGM (just 49 full members attending), changes subsequently made to the Memorandum and Articles of Association and other recent events. We had a most enjoyable and helpful catch up.

Fixing Dad shows the two brothers struggling to transform their father from an obese, barely mobile night-time security guard to a fighting fit endurance cyclist, public speaker and health activist. After lunch, I had arranged to meet Ursula at a Parliamentary Reception which was part of National Salt Awareness Week. This included a presentation by Anthony Whitington who is the Producer of Fixing Dad, the story of Geoff Whittington, a man whose lifestyle choices caught up with him until his two sons resolved to save him. Geoff was overweight, overworked and resigned to a premature death. Fixing Dad shows the two brothers struggling to transform their father from an obese, barely mobile night-time security guard to a fighting fit endurance cyclist, public speaker and health activist. The Reception was held in the Terrace Pavilion at the House of Commons. I had never been inside the Houses of Parliament before, despite

being a London Tourist Guide in the early 1970s! I was looking forward to it and had enough time to have a quick look around. My taxi driver dropped me off outside the Visitor’s entrance to the House of Commons and I spoke to the PC on duty about the rules on taking photographs. He also pointed out the view of Big Ben and the London Eye from New Palace Yard and also to note the view of Westminster Bridge from the Terrace Pavilion. Just 15 minutes after, I was through the very helpful security and out into New Palace Yard. I met up with Ursula, attended the Reception, spoke at length with Anthony Whitington about his attempts to support his father into a weight loss and fitness lifestyle and congratulated both him and his dad on a wonderful lesson that we can all learn from. Anthony announced that a followup of the programme would be shown this autumn. Every dietitian should look out for this. Some 12 hours later, events at Westminster would take on a very different course with the tragic killing of PC Palmer, the PC who had spent five minutes with me the previous day before I had entered the House of Commons. Sometimes in life there are experiences that continue to shape your thoughts, words and actions. That day was such a day. Fixing Dad is available in paperback, on Kindle, on an App and on a BBC 2 Film. www.NHDmag.com May 2017 - Issue 124

NETWORK HEALTH DIGEST

Coming in the next issue June 2017

• Special needs infant formula • Chronic obstructive pulmonary disease • Eating disorders • Fad diets • Sugar and salt: an update • PKU: the history of treatment _______

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Network Health Digest (NHD) at wwwNHDmag.com . . .

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

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May 2017: Issue 124

PAEDIATRIC NUTRITION: A HEALTHY START FOCUS

ON Paediatrics

Articles from our experts on infant weaning, formula milks, toddler snacks and nutrition in schools.

FROM THE EDITOR Emma Coates - NHD Editor

Welcome to our second Focus on supplement. Here we discuss the importance of getting a healthy nutritional start for our infant and child population. Infants benefit greatly from optimal nutrition within in the first 1,000 days of life. This ‘window of opportunity’ defines health for the rest of the child’s life. Improving nutrition and preventing malnutrition during this critical window of development can ‘program weight regulation and brain development’.1 We start with infant formula milk with Dr Emma Derbyshire examining formula in relation to full cream milk fats. Maeve Hanan RD then shares her thoughts on the nutritional content of follow-on formula, including the current evidence and advice for their use. The introduction of solid foods into an infant’s diet is often an exciting yet confusing time for many parents and healthcare professionals. Kate Roberts RD discusses the evidence base for complementary feeding, whilst clarifying the current recommendations and advice. Food and diet trends have become big news and big business, as we all become ever more aware of the benefits of tailored nutrition across the lifespan. The infant and toddler market is no exception. In Emma Derbyshire’s second article, she takes a closer look at the growing infant and toddler snack market, giving us an evaluation of the relevance and nutritional content of current products. Finally, nutrition in schools rounds up our Paediatric supplement. Maeve Hanan takes us through the various guidelines and recommendations which aim to improve nutrition and health promotion in schools. Enjoy the read. Emma Reference 1 Bhutta ZA. Early nutrition and adult outcomes: Pieces of the puzzle. [Comment] Lancet, 382 (9891) (2013), pp 486-487

www.NHDmag.com May 2017 - Issue 124 - Supplement

Contents

FOCUS ON PAEDIATRICS 3

Full cream milk in infant formula The latest innovations

9 FOLLOW-ON FORMULA Nutritional content and value 12 Complementary feeding An evidence-based guide

15 INFANT & TODDLER SNACK PRODUCTS A nutritional profile 18 Nutrition in schools Encouraging healthy food choices Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson

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

PAEDIATRIC SUPPLEMENT

INFANT FORMULA CONTAINING FULL CREAM MILK FATS: LATEST INNOVATIONS Dr Emma Derbyshire Independent Consultant Emma heads Nutritional Insight Ltd, an independent consultancy to industry, government, publishers and PR agencies. She is an avid writer for scientific journals and media. Her specialist areas are public health nutrition, maternal and child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire

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

The benefits of breastfeeding are well established, with exclusive breastfeeding recommended for up to six months of age. Presently, in Great Britain, less than 17% of women comply with these guidelines and manage to breastfeed ‘exclusively’ for the full six months. In circumstances where breastfeeding may not be possible, solely adequate, or suitable, closely matched alternatives are needed. This article aims to discuss the nutritional profile of infant formula that uses full-cream milk fats (whole cows’ milk) and explains how these products are evolving and integrating the latest science. It is widely acknowledged that breastfeeding is best, having many short and long-term benefits for both mother and child.1 The World Health Organisation (WHO) advises that ‘exclusive breastfeeding is recommended for up to six months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond’.2 The colostrum in particular (the yellowish sticky fluid produced after birth) is regarded as the perfect food for the newborn and should be introduced within the first hour after birth.2 Unfortunately, through no fault of their own, many women are not able

to breastfeed. There is evidence that long labours, maternal exhaustion and stress due to traumatic deliveries can all lead to delayed lactogenesis.3 Other work has shown that women delivering by emergency C-section have a higher proportion of breastfeeding difficulties (41%) compared to those delivering vaginally (29%).4 Medical conditions, such as tongue tie (ankyloglossia), can also affect an infant’s ability to latch on, leading to breastfeeding problems.5 A summary of studies investigating obstacles to breastfeeding is shown in Table 1. The World Breastfeeding Trends Initiative (WBFTi), supported by the Lactation Consultants of Great Britain, provides useful insights into patterns of infant feeding.6 As shown in Figure 1 overleaf, patterns of breastfeeding vary across Great Britain. Data from the WBFTi (2016) shows that three out of five women (60%) initially breastfeed within one hour of giving birth. However, by six months less than two out of 10

Table 1: Key obstacles to breastfeeding Obstacle Emergency C-section Employment and early return to work Infant tongue tie (ankyloglossia) Long labours, maternal exhaustion and stress Pain, difficulty latching on, relentlessness of early infant feeding Maternal obesity and related difficulties Sibling jealousy www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT Figure 1: Initiation and rates of exclusive breastfeeding for six months (% of women)

(17%) women in England breastfeed exclusively, with lower rates of 10 and 13% in Northern Ireland and Wales, respectively. Furthermore, the median duration of breastfeeding is three months in England, five days in Northern Ireland, six weeks in Scotland and just over two weeks in Wales (Figure 2).

Months

Figure 2: Median duration of breastfeeding (months)

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In instances where breastfeeding may not be possible, adequate or suitable, other options are needed.7 Infant formula that mimics the nutritional composition of breastmilk, particularly its fat composition, may be the next best alternative to provide nutrition and nurture to the infant.8 A recent study showed that of 81%

Table 2: Nutritional profile of milks (per 100ml)

Water g Energy Kcal Fat g Saturated fat g Carbohydrate g Protein g Vitamins Biotin mcg Folate mcg Niacin mg Retinol mcg Vitamin B1 mg Vitamin B12 mcg Vitamin B2 mg Vitamin B6 mg Vitamin C mg Vitamin E mg Vitamin K mcg Inorganics Calcium mg Chloride mg Copper mg Iodine mcg Iron mg Magnesium mg Phosphorous mg Potassium mg Selenium mcg Sodium mg Zinc mg

Milk, whole, pasteurised, average 87.6 63 3.6 2.3 4.6 3.4

Milk, semi-skimmed, pasteurised, average 89.4 46 1.7 1.1 4.7 3.5

Human milk, mature

2.5 8 0.2 36 0.03 0.9 0.23 0.06 2 0.06 0.6

3 9 0.1 19 0.03 0.9 0.24 0.06 2 0.04 NR

0.7 5 0.2 58 0.02 Tr 0.03 0.01 4 0.34 NR

120 89 Tr 31 0.02 10 96 157 1 42 0.5

125 87 Tr 30 0.03 10 96 162 1 44 0.5

34 42 0.04 7 0.07 3 15 58 1 15 0.3

87.1 69 4.1 1.9 7.2 1.3

Source: CoFID (2015)

of mothers using infant formula, 69% chose to feed their infants cows’ milk formula.9 WHOLE COWS’ MILK

As shown in Table 2, the fat content of whole cows’ milk is closely aligned with that of human milk. Studies show that milk fat contains around 400 different fatty acids, making it the most complex of all natural fats.10,11 Due to the natural presence of fats in whole cows’ milk, fewer manufactured vegetable oils need to be added to infant formulas using this as a base. Recently, the use of vegetable oils in formulas has been questioned, as these can influence

the balance of palmitic acid (16:0) which is an essential component of infant tissue lipids.12 It has also been associated with reduced fat and calcium absorption and harder stools when used in infant formulas,13 and its use is questionably ethical, namely due to wide scale deforestation.14 Whole cows’ milk is also a good provider of B vitamins, including B2 (riboflavin) and B12 and the minerals iodine, potassium and phosphorous (Table 2). Research has shown that the bioavailability of vitamin B12 in cows’ milk is substantially higher than equivalent amounts of cyanocobalamin, the synthetic form of this vitamin.15 Milk is also an important source of www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT choline, an essential nutrient that contributes to the growth and development of newborns.16 Cows’ milk also contains more L-carnitine than human milk which plays a central role in energy production, alongside being concentrated in tissues such as skeletal and cardiac muscle.17 Taken together, the range of nutrients present in whole cows’ milk provides a good base for infant formulas, though iron levels are lower than needed. At this point it should be considered that infant formulas are different to liquid cows’ milk in that they are fortified with iron and other nutrients, including vitamin D. The shortfalls in iron are partly why liquid cows’ milk is not advised for the first 12 months of life.18 Cows’ milk, however, tends to be associated with cows’ milk allergy (CMA). Findings from the latest EUROPREVALL Study (The prevalence, cost and basis of food allergy across Europe) found that <1% of children up to the age of two years had confirmed CMA. The diagnosis of CMA in this important study was tested using gold standard diagnostic procedures.19 MILK FATS

Human milk fat naturally contains palmitic acid that is esterified to the beta-position of triglycerides (an sn-2 bond), with evidence that this form favourably influences fatty acid metabolism and calcium absorption and improves bone matrix, stool consistency and the gut microbiome.20 The sn-2 bond is also regarded as being particularly important in the regulation of fat digestion and absorption.21 Presently, most supplemental formulas using vegetable oils as a main fat source contain palmitic acid with sn-1 and sn-3 bonds located at the external or alphaposition, which may impact on intestinal fat absorption.22,23 Formulas using dairy fat tend to contain more palmitic acid that is esterified in the sn2 position.24 Since the middle of the 20th century, cows’ milk fat has progressively been removed from infant formulas and replaced with vegetable oils.24 Latest evidence, however, indicates that dairy fat blended with a lower level of vegetable oils may be the best way to mimic the composition, structure and physiological properties of human breast milk oils.24 The 6

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combined use of different lipid sources also helps to balance out proportions of fatty acids, especially lauric, myristic and palmitic acid,25 as well as providing palmitic acid mainly in the esterified sn2 position of triglycerides.24 Whole cows’ milk fat also provides a range of lipophilic microconstituents. These include the vitamins A, D, E and K, carotenoids and phytosterols.26 A spectrum of bioactive components are also present in milk fat, including lipophilic antioxidants such as conjugated linoleic acid (CLA), coenzyme Q10 and phospholipids, with milk fat being regarded at the most easily digested fat in the human diet.11 CLA, in particular, has drawn particular attention for its biological activities, including its ability to modulate immune and inflammatory responses.27 It has recently been proposed that an ideal docosahexaenoic acid (DHA) target should be established for breast milk, with the view that this should be 0.3% or 1.0% of milk fatty acids.28 Koletzo and colleagues29 have also recommended that, when breastfeeding is not possible, infant formulas should provide DHA between 0.2 and 0.5 weight percent of total fat, with the minimum amount of Arachidonic Acid (ARA) equivalent to the contents of DHA being used. Recently, it has been put forward that both DHA and ARA should be included in infant formula, as breastfed infants obtain both of these fatty acids.30 With regard to trans fats, these are naturally present in whole cows’ milk but also present in breast milk via dietary transfer.31,32 Current opinion suggests that adding complex lipids and milk fat globule (MFG) membranes to vegetable oil-based infant formula could help to enhance infant development and reduce infections.33 For example, human fat contains an array of lipid component present as MFG, with a core containing triglycerides (98% of total lipids), surrounded by a MFG.24 Consequently, cows’ whole milk formulas have the advantage over those using semi-skimmed milk in that cows’ milk already contains complex natural fats and around 400 different fatty acids.10 This means that fewer processed vegetable-oils or other complex lipids need to be added.

Breastfeeding support and interventions should continue to be provided, especially as levels of ‘exclusive’ breastfeeding are so low.

IRON

There have been concerns about the low iron content of cows’ milk, with particular reference to iron deficiency (ID) risk in infants and toddlers.34 However, the iron content of human milk is also typically low, with the theory that an infant’s iron stores should be accumulated in pregnancy.35 Whilst iron is needed for infant neurodevelopment,36 excess iron may promote the growth of pathogenic iron requiring bacteria,35 indicating the importance of balance. The Global Standard for the composition of infant formula advises that the iron content of formula based on cows’ milk protein and protein hydrolysate should be a minimum of 0.3mg per 100kcal and maximum of 1.3mg per 100kcal.37 Revised guidelines relating to iron intakes in babies and children up to three years of age, have been issued in compliance with article 14 of the European Commission Regulation. This ensures that infant formula and follow-on formulae contain sufficient levels of iron, ranging from 0.6mg/100kcals to 2.00mg/100kcals, to support the formation of haemoglobin and red blood cells and a normal functioning immune system.38,39,40 VITAMIN D

Cows obtain vitamin D from both their diet and skin UVB exposure, with the vitamin D status of the cow impacting on the vitamin D content of milk produced in much the same way as human breast milk.41 Whilst there is great potential to further optimise the vitamin D content of cows’ milk, cows’ milk formulas are fortified to ensure that infants obtain suitable levels of vitamin D. The global standard for the composition of infant formula advised that infant formula contained a minimum of of 1µg and maximum of 2.5µg vitamin D per 100kcal.37

Health claims relating to the contribution of vitamin D to normal development of teeth and bones, have been formally approved and considered appropriate for infants and young children from birth to three years.42 Recently, the UK Scientific Advisory Committee on Nutrition report on vitamin D advised a safe daily intake of between 8.5-10μg/day for ages 0 up to one year (including exclusively breastfed and partially breastfed infants, from birth); and 10μg/day for ages one up to four years, although data was not sufficient to set Reference Nutrient Intakes.43 Amongst a sample of Dutch infants, median vitamin D intakes were 16-22µg/day for infants aged 0 to six months (increasing with age) and 13-21µg/day for infants aged seven to 19months (decreasing with age), indicating that a combination of infant formula, (fortified) foods and supplements was successful in achieving suitable intakes of vitamin D.44 DISCUSSION

Taking the latest evidence on board, breastfeeding is the gold standard when it comes to infant feeding and should be undertaken for at least six months exclusively.2 However, in reality, for physiological or other reasons, these guidelines are not being followed. In fact, latest data across Great Britain shows that less than one in five (20%) of women feed their infants exclusively for the first six months.6 Whilst interventions can clearly be put into place to improve rates of breastfeeding, other options also need to be provided. Whole cows’ milk is a good provider of nutrients, especially B2 (riboflavin), B12, iodine, potassium and phosphorous,45 along with choline16 and L-carnitine.17 Milk lipids in general are attracting much interest at present, due to the presence of bioactive compounds in the lipid fraction - this includes omega-3 and 6 www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT polyunsaturated fatty acids, conjugated linoleic acid, short chain fatty acids, gangliosides and phospholipids.46 Furthermore, it is coming to light that cows’ milk lipids and milk fat membrane extracts better mimic human milk structure and composition, yet few infant formulas use these, as they are more expensive than vegetable lipids.47 Subsequently, more recent evidence suggests that adding complex lipids and milk fat globules to vegetable-oil based infant formulas could help to support infant development and reduce infection risk.33 Animal studies indicate that grass-fed cows produce milk with an improved fatty acid profile. For example, a recent study has found that Holstein cows fed on cool-season pastures produce whole milk with a higher omega-3 and CLA content than those fed on pearl millet.48 Other work has also shown that pasture-fed cows, i.e. fed outdoors on grass and clover, produce milk containing significantly higher levels of saturated and unsaturated fatty acids, with more than a two-fold increase in CLA compared with milk produced from cattle fed indoors on a total mixed ration diet.49 Augmenting milk microconstituents by means of animal nutrition, rather than milk fortification, also helps to safeguard animal health.26 Formulas using whole cows’ milk also have potential to support the British dairy industry.

The British dairy industry is under pressure, with many dairy farmers expected to leave the industry, as they cannot continue to produce milk at a loss. This is largely due to increasing UK and EU supplies coupled with a stagnant global market.50 In New Zealand, infant formula is regarded as an ‘export superstar’ and has played a significant role in supporting the dairy industry which has now become a great success.51 Whilst breastfeeding should continue to be supported first and foremost, it should also be considered that alternatives are needed and the British dairy industry can play a role in providing these. CONCLUSIONS

In summary, whilst breastfeeding is regarded as the best way to feed infants, this is not always possible for a host of different reasons. Breastfeeding support and interventions should continue to be provided, especially as levels of ‘exclusive’ breastfeeding are so low. However, whilst the benefits of breastfeeding are well recognised, it should also be appreciated that other options are needed for women who cannot breastfeed through no fault of their own. In these instances, British full cream formulas provide an alternative option. These provide a good nutrient base, meaning that only subtle levels of fortification and fewer manufactured vegetable oils are needed.

Key points •

Exclusive breastfeeding is recommended for up to six months of age, as advised by the World Health Organisation (WHO.

•

Presently, less than 17% of women in Great Britain feed infants exclusively for the recommended sixmonth duration.

•

Cessation of breastfeeding appears to be attributed to a host of different reasons, including physiological and medical reasons.

•

In cases where breastfeeding is not possible, solely adequate, or suitable, closely matched alternatives are needed.

•

Full-cream milk fat infant formula provides an excellent nutrient base and spectrum of fatty acids.

•

There is growing evidence that lipid sources need to be carefully selected to better mimic breast milk, which includes the potential use of dairy fat.

Conflict of Interest This review was supported by Kendal Nutricare Ltd. The article was written independently and its content reflects the opinion of the author only.

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PAEDIATRIC SUPPLEMENT

FOLLOW-ON FORMULA Maeve Hanan Registered Dietitian, City Hospitals Sunderland, NHS

Maeve works as a Paediatric Dietitian in City Hospitals Sunderland. She also runs a blog called Dietetically Speaking.com which promotes evidencebased nutrition and dispels misleading nutrition claims and fad diets.

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

Follow-on formula can be used with infants from the age of six months alongside appropriate complementary feeding.1 Although there are some nutritional differences between infant formula and follow-on formula, for the majority of infants there is no benefit from switching to a follow-on formula.2 There has been a considerable amount of controversy surrounding the advertising practices related to follow-on formula; for example, in the UK it is illegal to advertise infant formula to the general public, however the advertising of follow-on formula is permitted.3 The World Health Organisation (WHO)4 and the UK Department of Health (DH)1 report that followon formula is unnecessary and an unsuitable substitute for breastmilk or first infant milk. Specifically, the UK government advises that ‘breast milk is the best form of nutrition for infants and exclusive breastfeeding is recommended for around the first six months of an infant’s life*’ and, unless advised by a health professional, ‘first milk’ is the only suitable alternative for breastmilk and ‘the only type of formula an infant requires until the age of 12 months, when cows’ milk can be introduced as a main drink into the diet’. *However the British Dietetic Association (BDA)5 and the European Society for Paediatric Gastroenterology,

Hepatology, and Nutrition (ESPGHAN)6 advise that complementary feeding can be introduced from four to six months of age and the Scientific Advisory Committee on Nutrition (SACN)7 is currently working on updating UK recommendations on complementary feeding.

UK STATISTICS

As displayed in Table 1, the UK Diet and Nutrition Survey of Infants and Young Children, 20111 identified that although follow-on milk was most commonly given to infants aged seven to 11 months, 32% of babies aged four to six months were also given follow-on formula. Furthermore, this survey found that by 10 to 11 months, 69% of all mothers had given their baby follow-on formula at some stage; which is an increase from 53% in 2005. SACN’s analysis of the 2005 UK Infant Feeding Survey8 found that younger mothers, those from lower socioeconomic groups and those with lower educational levels were the least likely to try to continue breastfeeding, were more likely to use follow-on formula and were more likely to provide this at an earlier age. SACN also reported that at four to six months, the main reasons given for switching to follow-on formula included: • past experience using this with previous children (23%); • believing it was better for the baby as it provides more nutrients (20%); • thinking that the baby was still hungry after being fed ordinary infant formula (18%);

Table 1: Use of follow-on formula in infants Age group

Percentage use of follow-on formula

4 to 6 months

32%

7 to 9 months

56%

10 to 11 months

59%

12 to 18 months

16% www.NHDmag.com April 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT Table 2: Nutritional comparison per 100ml of breast milk, infant formula and follow-on formula11,12 Nutrient

RNI for infants 6-12 months**

Breast milk per 100ml

Infant formula per 100ml

Follow-on formula per 100ml

Energy (kcal)

710-960

60-70

Protein (g)

12.7-14.9

1.3

1.8-3

1.8-3.5

Fat (g)

approx. 28-37 (i.e. 35% total energy)

4.1

4.4-6

4-6

Carbohydrate (g)

approx 89-120 (i.e. 50% total energy)

7.2

9-14

Iron (mg)

4.3-7.8

0.07

0.3-1.3

0.6-2

Calcium (mg)

524

50-140

Sodium (mg)

276-345

20-60

Vitamin A (µg)

350

60-180

Vitamin D (µg)

8.5-10 (safe intake)

0.2-3.1

1-2.5

1-3

Vitamin C (mg)

10-30

Thiamine (mg)

0.18-0.23

0.02

0.06-0.3

Riboflavin (mg)

0.4

0.03

0.08-0.4

Niacin (mg)

4-5

0.2

0.3-1.5

Vitamin B6 (mg)

0.2-0.4

0.01

0.035-0.175

Linoleic acid (mg)

>1% total energy13

560

300-1200

Linolenic acid (mg)

>0.2% total energy

**This is a combination of the nutritional requirements of age groups 4-6 months, 7-9 months and 10-12 months from the Great Ormond Street guide Nutritional Requirements14; this is not suitable for devising nutritional requirements.

• recommendations from doctors or health visitors (22%). NUTRITIONAL CONTENT

Follow-on formula is often advertised for use by ‘hungrier babies’ as it is casein based which may take longer to digest than whey based formulas; however, this claim is not supported by the evidence base.8 Follow-on formulas can be higher in protein, energy, calcium, iron and other micronutrients compared to breast milk.9 According to the American Academy of Paediatrics Committee on Nutrition and the Australian National Health and Medical Research Council, there are no established advantages of follow-on formula over breast milk in relation to changes in its fat, protein, carbohydrate, calcium and sodium composition.10 WHO has highlighted that follow-on formula can be higher in protein than those recommended for adequate growth and development of infants and young children.4 Research is emerging that 10

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most infants in high income countries exceed their protein requirements and a higher protein intake in early life may be associated with a higher risk of obesity in later life.6 For this reason and also because the current minimum protein level permitted in follow-on formula (1.8g/100kcal) remains higher than that found in breast milk, the European Food Safety Authority (EFSA) has recently completed a public consultation to consider lowering this minimum level to 1.6g/100kcal and have also lowered the maximum permitted protein level from 3.0 to 2.5g/100kcal.6 Follow-on formulas may be useful for those with low iron levels, or a poor weaning diet over the age of six months; however, the majority of infants won’t need the additional iron that these formulas provide if they have an adequate weaning diet.9,10 There is mixed evidence from studies which compared iron supplemented follow-on formulas with cognitive outcomes and also dietary iron intake in infants and cognitive outcomes.6

PAEDIATRIC

It is clear that the follow-on formula market is thriving, despite the limited supporting evidence for their nutritional use; There is some evidence that follow-on formula supplemented with DHA (an omega-3 fatty acid which is included in most infant formulas in the UK) may improve short-term visual function in infants, which is important, as some European infants and young children may be at risk of a low omega-3 intake. However, genotype and fish intake also play a role in DHA status and studies using DHA-enriched egg yolk as part of complementary feeding have also been shown to increase DHA levels.6 ADVERTISING LAW

Numerous studies have found that the labelling and marketing of follow-on formula can persuade parents to switch from breastfeeding to followon formula unnecessarily when their baby reaches six months4,8,16-17 and that the advertising of follow-on formula may be contributing to the low levels of breastfeeding found in the UK.8 (The 2010 infant feeding survey reported: 81% breastfeeding initiation, 69% breastfeeding at one week, only 34% breastfeeding at six months.18) Follow-on formula can also be confused with first infant formula; SACN (2008) identified that this is most likely to occur in lower socioeconomic groups and in general that ‘many mothers are unclear about the distinction between the different types of formula’.2,8 Therefore, in 2010 the World Health Assembly Resolution appealed to ‘infant food manufacturers and distributors to comply fully with their responsibilities under the International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly Resolutions’, as these marketing strategies were undermining optimal infant feeding.4,15 The UK government now mandate that the labelling of follow-on formula must state the following:3,19

• ‘The product is suitable only for particular nutritional use by infants over the age of six months.’ • ‘The product should form only part of a diversified diet.’ • ‘Infant formula and follow-on formula shall be labelled in such a way that it enables consumers to make a clear distinction between such products so as to avoid any risk of confusion between infant formula and follow-on formula, (including the age range in an appropriate font size).’ • ‘The superiority of breastfeeding via an ‘Important Notice’.’ Although it is illegal to advertise or promote infant formula (with the exception of information for a scientific or trade publication), there are no restrictions on the promotion of follow-on formula beyond the rules related to packaging described above; however more stringent promotion laws have been called for by SACN in order to reduce the amount of parents switching their babies on to follow-on formula at a young age.8,19 CONCLUSION

It is clear that the follow-on formula market is thriving, despite the limited supporting evidence for their nutritional use; with the exception of a potential benefit for some infants over six months with anaemia or an inadequate weaning diet. Although there are clear labelling laws related to this type of formula in the UK, the fact that there are few advertising restrictions increases the risk that infants may be inappropriately switched to a follow-on formula. As health professionals it is our role to remain consistent with the message that ‘breast is best’ until at least 12 months and where formula is used, there is no benefit to switching from infant formula to a follow-on formula for the majority of infants. www.NHDmag.com April 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT

COMPLEMENTARY FEEDING: THE EVIDENCEBASED GUIDE TO WHAT, WHEN AND HOW Kate Roberts Freelance Dietitian, Kate Roberts Nutrition

Kate is a Freelance Dietitian with a wide range of clinical experience of working with adults and children having previously working in the NHS. Her specialities are Diabetes and Allergies.

In 2002, the World Health Organisation (WHO)1 recommended that mothers should breastfeed exclusively until six months and then begin complementary feeding. This is what the majority of mothers in the UK are being advised.2 But is this the correct message? Are people following the advice? What can and should dietitians be recommending? Complementary feeding is the period when infants no longer get all the nutrients they need via breast milk or infant formula, therefore, other foods and liquids need to be introduced.1 It can also be called weaning, but this term can be confused with weaning off breastmilk onto infant formula. The overall aim of complementary feeding is for children to be getting the right nutrients at the right time and eventually eating more or less the same as the rest of their family by the age of one.1 New guidelines from the Scientific Advisory Committee on Nutrition (SACN) have recommended that Vitamin D should be supplemented in breastfed babies from birth.7 Nutrients which are needed in addition to breast milk and formula from four months are iron and zinc.11 There have been some excellent studies recently which have changed our outlook on complementary feeding. Here, I summarise the main points of each. Learning early about peanuts (LEAP) study 20153 This landmark study found that the introduction of peanuts to high risk infants reduced the incidence of peanut allergy. The LEAP study found that only 3% of the children who consumed peanuts between the ages of four to 11 months developed a peanut allergy by the age of five, compared to 17% in the group that avoided them. This trial was a game-changer in the advice that should be given to new parents, as, for decades, healthcare professionals

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had been recommending that allergens should be avoided. Enquiring about tolerance (EAT) 20164 In this study, six allergenic foods were introduced to breastfed infants from three months of age. The allergens included: peanut, cooked egg, cows’ milk, sesame, whitefish, and wheat. Although they were unable to statistically prove that introducing these foods reduced the incidence of allergy, they did prove that introducing them was safe; there were no cases of anaphylaxis and doing so did not adversely affect growth. The study did indicate that reducing the risk of allergy was dose-dependent. When it was strictly adhered to, there was a significant reduction in the development of allergies. Canadian Healthy Infant Longitudinal Development (CHILD) Study, 20165 This Canadian study included prospective questionnaires and skin prick testing, specifically looking at cows’ milk, egg and peanut. It found that exclusive breastfeeding up to six months did not affect the sensitisation of foods apart from cows’ milk. It did find that there was benefit to introducing the three allergens before the age of one. Following these studies, the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition released a position paper in early 2017 on Complementary Feeding.6

I have based the following recommendations on the evidence above, as well as recommendations from ESPGHAN. DO PEOPLE FOLLOW THE CURRENT GUIDANCE?

Well, the short answer is no. Not all mothers can or want to exclusively breastfeed until six months for a variety of reasons. In the UK in 2010, 75% of parents had already introduced food by five months and only one in 100 mothers exclusively breastfed until six months.8 ESPGHAN suggests promoting exclusive breastfeeding until 17 weeks and having six months as a goal.6 WHEN CAN COMPLEMENTARY FOODS START TO BE INTRODUCED?

By 17 weeks infants possess the gastrointestinal and renal function to cope with complementary food.6 The necessary motor skills are developed between four to six months. It is actually more beneficial for acceptance of flavours and textures and avoidance of allergy to start complementary feeding early, somewhere between four to six months (but not before 17 weeks).6 It is good to start introducing solids as soon as the infant is ready. Parents should not delay the introduction of complementary foods past six months (26 weeks). There is, however, some confusion, as many healthcare professionals recommend that parents wait until six months unless there is a particular need. It is important to try and communicate with healthcare professionals in your wider multidisciplinary team to advise them of what you are advising and why. Signs that an infant is ready for complementary food:2 • Can hold their head up • Can bring their fingers to their mouth • Showing interest in food

HOW SHOULD COMPLEMENTARY FEEDING BEGIN?

Methods 1. Traditional: spoon feeding Benefits: • It’s an easy way to provide the infant with lots of new flavours. • Parents feel confident that the infant is eating. Potential risks: • Parents could give the infant the amount they think is right and not give the child the chance to stop when they are full. This can lead to children losing their satiety signals and may even be linked to obesity.12 • Purees can often be a mixture of different foods and infants will, therefore, not identify different flavours and what they are eating. 2. Baby-led weaning Benefits: • Infants see what food they are eating • Infants only eat what they want • Convenient • Eating the same as the whole family Potential risks: • Choking • Not getting enough to eat • Not getting enough iron Things to remember with baby-led weaning: • Avoid foods that are easy to choke on coin shaped foods (like slices of carrot and chopped sausage), grapes and raw apple which breaks off easily. • Encourage an iron-rich source at every meal time. • Ensure that baby is getting a high-energy component to every meal.9

Table 1: Traditional complementary feeding stages10 1

Around six months

Thicker consistency with some lumps; soft finger foods can also be introduced at this stage

Nine to 12 months

Mashed, chopped, minced consistency; more finger foods

12 months and older

Mashed, chopped family foods and a variety of finger foods

• Fruit and vegetables • Rice, pasta, potatoes, yam, bread and cereals • Meat, fish, pulses and eggs • Yoghurt, custard and cheese

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PAEDIATRIC SUPPLEMENT Table 2: Introducing allergenic foods and other nutrients Food/Nutrient Added sugar and salt Iron Gluten

Peanuts

Other allergens (such as cows’ milk, soy, egg etc) Honey

When they should be introduced Avoid in any complementary foods and drinks There is a high demand for iron in infants over six months, especially in breastfed babies; therefore, iron-rich foods should be encouraged. It is safe to introduce gluten after four months, it is not linked to an increase of incidence of coeliac disease or Type 1 diabetes. Large quantities, however, should be avoided. Infants who have severe eczema and/or egg allergy) should check with an ‘appropriately trained healthcare professional’ before having nuts. This may mean that they need to undergo skin prick testing and supervised introduction of peanuts. If the child has mild to moderate eczema, currently it is suggested that peanuts are introduced from six months of age. For those who do not have eczema, peanuts can be introduced as soon as some basic complementary foods have been introduced. They all may be introduced as soon as complementary feeding commences, unless diagnosed as having an allergy. Avoid until after 12 months.

A mixture of both would ensure the benefits of both methods. It is important that health professionals manage expectations of complementary feeding; it can be messy and frustrating when infants pull faces and refuse the food that has taken hours to prepare. Parents need to be aware that it may not be easy; as with every other part of parenting, you can never plan for how babies are going to react! THE CONTENT OF COMPLEMENTARY FOOD

A healthy diet should be encouraged from the start, with a focus on introducing a wide range of foods, especially bitter ones such as green vegetables. Infants may pull a face when trying a lot of foods for the first time; this is a natural reaction to a new flavour and does not necessarily indicate disgust. The key should always be to offer new foods multiple times which will help children to accept different flavours.

CONCLUSION

Dietitians can now recommend introducing complementary foods as soon as the infant is ready after 17 weeks, including allergenic foods. If a baby is at high risk of peanut allergy, it is essential to refer to an allergy team before commencing peanut-based foods. It is up to parents what method of complementary feeding style they use. A mixture of both traditional and baby-led weaning can be encouraged; in this way, parents are able to introduce flavours and allergens in a timely manner. However, they do need to watch for signs that their infants are full so they do not overfeed when using a spoon. From six months they can start letting their baby take control with finger foods and enjoy the benefits of baby-led weaning whilst continuing to introduce wider flavours and textures.

References 1 World Health Organisation (WHO) (2002). Complementary Feeding. Report of the Global Consultation. Geneva. 10-13 December 2001. Summary of Guiding Principles. http://apps.who.int/iris/bitstream/10665/42739/1/924154614X.pdf?ua=1 Accessed March 10, 2017 2 www.nhs.uk/Conditions/pregnancy-and-baby/Pages/solid-foods-weaning.aspx 3 Du Toit, G et al (2015). Randomised Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. N Engl J Med 2015; 372:803-813 February 26, 2015 DOI: 10.1056/NEJMoa1414850 4 Perkin MR et al (2016). Randomised Trial of Introduction of Allergenic Foods in Breastfed Infants. N Engl J Med 2016; 374:1733-1743 May 5, 2016 DOI: 10.1056/NEJMoa1514210 5 Tran MM et al (2016) The Effects of Infant Feeding Practices on Food Sensitisation in a Canadian Birth Cohort. Am J Respir Crit Care Med 193; 2016: A6694 www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A6694 6 Fewtrell M et al. Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. JPGN, Vol 64, Number 1, January 2017 7 Scientific Advisory Committee on Nutrition (2016). Vitamin D and Health. www.gov.uk/government/groups/scientific-advisory-committee-on-nutrition 8 McAndrew F et al (2012). Infant Feeding Survey 2010. London, ONS: The Information Centre for Health and Social Care. 9 Daniels L et al. Baby-Led Introduction to SolidS (BLISS) study: a randomised control trial of a baby-led approach to complementary feeding. http:// bmcpediatr.biomedcentral.com/articles/10.1186/s12887-015-0491-8 10 Table from: www.bda.uk.com/foodfacts/WeaningYourChild.pdf 11 Thomas B and Bishop J (2007). Manual of Dietetic Practice. Blackwell Publishing Ltd, Oxford 12 Townsend E, Pitchford NJ. Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a casecontrolled sample. BMJ Open 2012; 2: e000298. doi:10.1136/bmjopen-2011-000298

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PAEDIATRIC SUPPLEMENT

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

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

THE NUTRITIONAL PROFILE OF INFANT AND TODDLER SNACK PRODUCTS The infant and toddler snack market is rapidly expanding, with an increased demand for specialist products in this important life-stage. This article, summarising recent analysis by Dr Emma Derbyshire, provides a nutritional evaluation of UK infant and toddler snack foods. This current analysis evaluates the nutritional profile of 98 snack products currently available in the UK typically found in supermarkets and pharmaceutical stores for this life-stage. Findings showed that fruit-based snacks dominate the market, although some vegetable-based products are beginning to emerge. Most products (48.5%) had thiamine on their nutrition label yet overlook nutrients where shortfalls are evident (vitamin D, iron). This paper highlights that there is still much work to be done in this important and growing sector. It is becoming increasingly apparent that nutrition in the early years is central to later health.1 The early years period also falls within the first 1,000 days of life (from conception to the second birthday), which is regarded as being a critical window of opportunity to optimise a child’s health.2 A nutritional analysis of commercial infant and toddler foods sold in the United States which included snacks, found them to be particularly high in sugar and sodium.3 Snacks are typically defined as ‘eating occasions between meals’.4 Amongst young children, a routine of three meals and two snacks a day is a useful benchmark to follow.5 It is, however, increasingly being recognised that the trend of ‘snackification’ (eating on the go) is showing no signs of subsiding.6 Whilst this trend is flourishing amongst adults, it also appears to be creeping in within the infant/toddler market. Bearing this

in mind, it is critically important that products available are appropriate in terms of flavour exposures and their nutritional profile. METHODS

Data collection Proportions of declared energy (kJ), energy (kcal), protein (g), carbohydrate (g), total sugar (g), total fat (g), saturated fat (g), fibre (g), salt (g) and sodium (g) content were examined along with the presence on additional micronutrients on the food label. Where sugars were not used to sweeten foods, the main source of sweetness was listed. Where oils were added to foods, the main oil and percentage contribution to the product was collated. The range of products available was also analysed by product type and age category for which it was marketed. Products were identified using three different supermarket websites and one pharmaceutical website. The search terms ‘infant’ and ‘toddler’, combined with ‘snacks/snack foods’ were used to identify the products. Infant formulas, fortified milk, beverages and ready meals were excluded from the analysis. Data was categorised into the following groups:

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PAEDIATRIC SUPPLEMENT Table 1: Macronutrient profile of infant/toddler snack foods (per 100g) Product

Energy (kcal)

Protein (g)

CHO (g)

Sugars (g)

Fat (g)

Saturated fat (g)

Fibre (g)

Salt (g)

Biscuits

429.6

9.3

68.8

16.5

12.8

4.1

4.9

0.4

Bars

386.7

6.3

97.2

31.7

11.9

2.1

6.4

0.1

Crisps/puffs

453.4

6.8

65.4

6.3

18.1

2.6

3.5

0.5

Crackers/ bread sticks

444.6

11.9

65.7

2.5

14.3

4.9

3.4

0.6

Rice cakes

388.2

7.3

85.1

12.0

1.6

0.4

1.9

0.1

Fruit-based snacks

317.3

2.6

69.2

54.9

2.2

1.0

7.5

0.1

Vegetablebased snacks

431.3

7.6

69.8

16.1

12.4

1.2

6.2

0.5

1 Biscuits 2 Bars 3 Crisps/puffs 4 Crackers 5 Rice cakes 6 Fruit-based snacks 7 Vegetable-based snacks Nutrients listed on the food labels were also collated. RESULTS

A total of 98 snack products were identified. Of these, one-quarter were fruit-based snacks (dried fruit pieces/gummies), 22% were biscuits, 17% rice cakes, 15% crisps or puffs, 13% were bars, 6% vegetable-based snacks and 5% crackers or breadsticks. The mean macronutrient profile of infant/ toddler snacks is presented in Table 1. Fruitbased snacks had the lowest energy, protein, fat and saturated fat content. They also had the highest fibre content (along with snack bars). Pairwise comparisons showed that fruit-based snacks and bars contained significantly more fibre content than options such as rice cakes (P<0.05). The total sugar content of fruit-based products was, however, the highest at 54.9g. Crackers/bread sticks had the highest protein content and provided most salt. Crisps and puffs typically had the highest total fat content. Pairwise analysis found levels of saturated fat were significantly higher in biscuit, crisps/puffs and crackers/breadstick products compared with rice cake products (P<0.05). 16

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Vegetable-based snacks were surprisingly high in energy and total fat, possibly due to oils added. Sunflower oil was used in the majority of products (62%), although over one-third (36%) used palm oil (Figure 1). An analysis of nutrients listed on food labels revealed that thiamine was the most commonly reported nutrient (listed on 48.5% of products), possibly due to flour fortification. After this, less than 10% of products reported listing key nutrients such as iron, vitamin D, zinc or calcium, indicating that the nutritional density of infant/ toddler products appears to be low (Figure 2). DISCUSSION

It is important that the right food choices are available for infants and toddlers, which help to satisfy appetite whilst providing a good source of nourishment. It is well established that earlylife experiences with healthy tastes and flavours can go a long way towards promoting healthy eating. This, in turn, can play a significant role in addressing the many chronic illnesses associated with poor food choices.7 Whilst fruit-based snacks low in fat are a great provider of fibre, they also contain a high amount of fruit sugars. Given this, it would be good to see a greater range of savoury and vegetable-based products, preferably with a lower fat content and using fewer oils such as palm oil.8 It is important that a range of products are eaten to disperse intakes of fat, protein and fibre. Equally, snacks, such as fresh vegetables and fruits, should not be overlooked.

Figure 1: Types of oils used in infant/toddler foods

Figure 2: Micronutrients listed on food labels (% of products)

Whist it is good to see that most products are now moving away from using ‘added sugars’, this does not necessarily mean that they are moving away from sources of ‘sweetness’ per se, with alternatives creeping in. With regard to salt content, this was highest in crackers and breadstick-type products, though most products are well balanced in this sense. The micronutrient profile of commercial infant/ toddler snack products was somewhat disappointing, indicating that current snack products appear to be more about providing fuel and different flavours. There is certainly scope to evaluate the vitamin D content of infant and toddler foods given deficiency concerns and poor compliance with supplements during the early years.

CONCLUDING REMARKS

Taken together, whilst the infant and toddler snack product market is evolving, there is still much work to be done. Improvements are being made in terms of not using added sugars and monitoring of salt levels. However, when looking at the ‘variety’ of foods available, sweet tasting products continue to dominate in favour of more savoury and alternative tastes. Whilst current snack products appear to provide a basic source of fuel, they do not seem to be provide much more beyond this. Fruitbased snacks do appear to be an important provider of fibre, but the general micronutrient profile of current infant/toddler commercial snack foods seems to be lagging behind. www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT

NUTRITION IN SCHOOLS Maeve Hanan Registered Dietitian, City Hospitals Sunderland, NHS

Creating a healthy school environment which encourages nutritious food choices has numerous benefits for children; it can support general health and growth, improve dental health, reduce the risk of gaining excess weight, foster longer-term healthy habits, improve energy and mood levels and also optimise learning.

Schools have opportune contact with families and the ability to signpost them to healthy lifestyle information. Schools can also help to reduce the gap of food poverty and health inequality by providing access to healthy food during the school day and by running initiatives such as breakfast clubs; which have been associated with improved educational attainment, better school attendance and improved general health.1

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

SCHOOL FOOD STANDARDS

In the UK, school meals are free for children from reception to Year 2 and also for those who receive certain income support or tax credits as outlined in the Education Act 1996.2 In England, the government-run ‘School Fruit and Vegetable Scheme’ provides four- to six- year-old pupils in state-funded schools with a free daily piece of fruit or vegetable outside of lunchtime, although it is not mandatory for schools to participate in this scheme.3 Some pupils are also eligible to receive up to 250ml of free or subsidised milk products each school day via the school milk subsidy scheme.4 English local authority schools, academies which opened before 2010 and certain free schools must adhere to the ‘School Food Standards’ outlined in the updated ‘School Food Plan’ which was implemented in England in 2015, and all remaining schools can sign up to these standards voluntarily.3,5 These Standards aim to improve the nutrition

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and dietary habits of school-aged children with an emphasis on creating a positive environment for meals and educating children about sustainable healthy choices and the importance of a varied and balanced diet. Ofsted supports the School Foods Standards and there are also award schemes to encourage active participation, such as ‘The Children’s Food Trust Excellence Award’ and ‘The Food for Life Partnership’.5 The School Food Standards work alongside the ‘Government Buying Standards for Food and Catering Services’ and applies to all food provided in schools up to 6pm, including: breakfast clubs, snacks at mid-morning break, school lunches, after school clubs, vending machines and tuck-shops.5 However, they do not apply to: parties, fundraising events, cookery sessions, or celebrations of religious/cultural occasions.4 These standards also provide specific guidance on appropriate portion sizes for different age groups, how to manage food allergies and intolerances and signposting to resources, such as: example menus, recipes, checklists, information on interpreting food labels and cooking tips for school caterers.5 Specifically, the School Food Plan recommend:3,5 • plenty of fruit, vegetables and unrefined starchy foods; • some meat, fish, eggs, beans, milk and dairy (and dairy-free alternatives) daily;

Figure 1: Standards for school lunches5

The standards for school lunches

Starchy foods

Fruit and Vegetables

Milk and dairy

One or more portions of food from this group every day

One or more portions of vegetables or salad as an accompaniment every day

A portion of food from this group every day

Three or more different starchy foods each week

One or more portions of fruit every day

One or more wholegrain varieties of starchy food each week

A dessert containing at least 50% fruit two or more times each week

Lower fat milk must be available for drinking at least once a day during school hours

Starchy food cooked in fat or oil no more than two days each week (applies across the whole school day)

At least three different fruits and three different vegetables each week

Bread - with no added fat or oil - must be available every day

Healthier drinks

Foods high in fat, sugar and salt Meat, fish, eggs, beans and other non-dairy sources of protein

A portion of food from this group every day A portion of meat or poultry on three or more days each week Oily fish once or more every three weeks For vegetarians, a portion of non-dairy protein on three or more days each week A meat or poultry product (manufactured or homemade, and meeting the legal requirements) no more than once each week in primary schools and twice each week in secondary schools (applies across the whole school day)

No more than two portions of food that have been deep-fried, batter-coated, or breadcrumb-coated, each week (applies across the whole school day) No more than two portions of food which include pastry each week (applies across the whole school day) No snacks, except nuts, seeds, vegetables and fruit with no added salt, sugar or fat (applies across the whole school day)

applies across the whole school day Free, fresh drinking water at all times The only drinks permitted are: •

Plain water (still or carbonated)

•

Lower fat milk or lactose reduced milk

•

Fruit or vegetable juice (max 150mls)

•

Plain soya, rice or oat drinks enriched with calcium; plain fermented milk (e.g. yoghurt) drinks

•

Combinations of fruit or vegetable juice with plain water (still or carbonated, with no added sugars or honey)

•

Combinations of fruit juice and lower fat milk or plain yoghurt, plain soya, rice or oat drinks enriched with calcium; cocoa and lower fat milk; flavoured lower fat milk, all with less than 5% added sugars or honey

•

Tea, coffee, hot chocolate

Savoury crackers or breadsticks can be served at lunch with fruit or vegetables or dairy food No confectionery, chocolate or chocolatecoated products (applies across the whole school day) Desserts, cakes and biscuits are allowed at lunchtime. They must not contain any confectionery Salt must not be available to add to food after it has been cooked (applies across the whole school day) Any condiments must be limited to sachets or portions of no more than 10 grams or one teaspoonful (applies across the whole school day)

Combination drinks are limited to a portion size of 330mls. They may contain added vitamins or minerals, and no more than 150mls of fruit or vegetable juice. Fruit or vegetable juice combination drinks must be at least 45% fruit or vegetable juice

• limiting foods and drinks high in fat, sugar and salt; • increasing the iron, zinc and calcium content of school menus; • free drinking water to be available at all times; • hot lunches to be available when possible to encourage at least one hot meal per day for pupils; • facilities to be available for those who bring in packed lunches;

• detailed guidance for school lunch standards as outlined in Figure 1. TACKLING CHILDHOOD OBESITY IN SCHOOLS

Obesity is an increasingly important issue to be aware of in a school setting. Figures from 2014 to 2015 in England reported that more than a fifth of children in reception were overweight or obese (22.6% for boys, 21.2% for girls), and roughly a third of children in year six www.NHDmag.com May 2017 - Issue 124 - Supplement

PAEDIATRIC SUPPLEMENT Table 1: Childhood obesity health risk Endocrine problems

Type 2 diabetes, impaired glucose tolerance, premature puberty

Respiratory disorders

Asthma, obstructive sleep apnoea, reduced exercise tolerance

Cardiovascular disorders

Hypertension, hyperlipidaemia

Musculoskeletal problems

Blount’s disease, back/knee/hip/ankle/foot pain

Psychological problems

Low self-esteem, stress and anxiety, poor social skills, behavioural problems, increased risk of eating disorders

Gastrointestinal disorders

Non-alcoholic steatohepatitis (NASH)

Increased risk of chronic diseases in adulthood

Heart disease, stroke, dementia, certain cancers (e.g. breast, colon, endometrial), liver disease

Other issues

Fatigue, skin infections due to moisture in skin folds, the potential to affect lifetime attainment, possible reduced longevity

were overweight or obese (34.9% boys, 31.5% girls).6 This is worrying as childhood obesity is related to numerous health risks as outlined in Table 1.7-8 In order to tackle the issue of increasing childhood obesity levels, in 2016 the World Health Organisation (WHO) released its Report of the Commission on Ending Childhood Obesity which highlights ‘health, nutrition and physical activity for school aged children’ as one of its core areas for improvement.9 Specific recommendations within this report include: • promoting healthy school environments; • health and nutrition literacy as a core part of the curriculum; • physical activity in schools including good quality PE; • developing healthy standards for food and drink provided in schools; • cookery classes for pupil and their parents or guardians; • regularly monitoring children’s growth at school or with the family’s GP to identify those who need extra support or input; • banning the marketing of unhealthy food and drinks in areas where children and adolescents gather including schools, in line with Resolution 63.14 from the World Health Assembly10 as school aged children, and particularly adolescents, are vulnerable to marketing strategies of unhealthy options. 20

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In response to this, the UK government also released its ‘Childhood Obesity: A Plan for Action’ in 2016.1 Working with schools is described as a vital part of this plan with four of the 14 main areas targeted to for improvement being directly linked to health promotion within school: 1. Encouraging an hour of physical activity per day for all children Research shows that physical activity levels start to reduce from the age that children start school, which is worrying, as physical activity has numerous benefits such as improved fitness, healthier bones and joints, mood, sleep quality and academic performance.1,10 Therefore, all primary school children should receive at least 30 minutes of physical activity within school time via activity at break times, extra-curricular clubs, PE, active classes or other physical activity opportunities; and the remaining 30 minutes should occur outside of school. The proceeds from the soft drinks industry levy is to provide extra funding for promoting physical activity in schools. This will be taken into account during Ofsted inspections and the new healthy schools rating scheme. Public Health England will be devising further advice for the academic year of 2017-2018 about how schools can utilise all relevant resources to create a healthier lifestyle for its pupils.

Schools clearly play an important role in influencing the nutrition, health and wellbeing of children.

2. Improving sport and physical activity programmes in schools From September 2017, all primary schools in England should have access to good quality local and national sport and physical activity programmes which may include strategies to promote walking and cycling to school. These programmes will be co-ordinated by county sports partnerships, national governing bodies of sport, the Youth Sport Trust and other relevant providers. 3. Creating a healthy rating scheme for primary schools A voluntary Ofsted recognised scheme for UK primary schools will be introduced in September 2017 to encourage healthier eating and more physical activity, which will include an annual competition to celebrate schools with the best projects for promoting health and tackling obesity. In 2017 Ofsted also plans to produce a best practice report to provide guidance for schools on healthy eating, physical activity and reducing obesity levels.

4. Making school food healthier The Department for Education in the UK plans to update the current School Food Standards to include the most recent evidence-based guidelines on nutrition (for example, the updated recommendations on carbohydrates and sugar). The Secretary of State for Education will also run a campaign to encourage all schools to adhere commit to the School Food Standards, as some academies and free schools are not currently required to follow this scheme.3 Also, 10 million pounds per year from the soft drinks levy has been proposed to set up more healthy breakfast clubs in the UK. CONCLUSION

Schools clearly play an important role in influencing the nutrition, health and wellbeing of children. Hopefully the recent emphasis on this in school specific guidelines, which aim to tackle the global health issue of childhood obesity, will result in improved compliance with school food standards in order to optimise the health of all pupils and set them up for lifelong healthy habits. www.NHDmag.com May 2017 - Issue 124 - Supplement

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