Network Health Digest - July 17 by NH Publishing Ltd

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

NHDmag.com

July 2017: Issue 126

IMPROVING GUT HEALTH DIETETIC VIRTUAL CLINIC CHILDHOOD OBESITY PLANT STEROLS & STANOLS CYSTIC FIBROSIS

Children's eating disorder Page 41

Aptamil Pepti for the eﬀective management of cows’ milk allergy

RELIEVE

cows’ milk allergy symptoms1 with 97% eﬃcacy2

REDUCE

incidence of atopic dermatitis up to ﬁve years3 NOW PROVEN4

REASSURE

with the UK’s most palatable extensively hydrolysed formula4*

For further information contact our Healthcare Professional Helpline on 0800 996 1234 or visit www.eln.nutricia.co.uk/cma References: 1. Verwimp JJ et al. Eur J Clin Nutr. 1995;49 (Suppl1):S39-S48. 2. Giampietro PG et al. Pediatr Allergy Immunol. 2001;12:83-86. 3. Arslanoglu S et al. J Biol Regul Homeost Agents. 2012;26:49-59. 4. Campden BRI conducted a blind taste test using a home usage design with a sample of 100 Dieticians and General Practitioners from 16.11.2016 to 09.12.16. Participants rank ordered the extensively hydrolysed formula (EHF) milk samples (Danone Aptamil Pepti, Abbott Similac Alimentum, Nestle SMA Althera and Mead Johnson Nutramigen LGG) in term of overall liking and answered a series of attitudinal questions in relation to the impact of EHF’s palatability on infants with CMA and their families. The results from the ranking showed that the Danone Aptamil Pepti sample was liked signiﬁ cantly more than all the other three samples tested. * A home usage test assessment was carried out between 16/11/16 and 9/12/16 on the 4 products indicated for cows’ milk allergy from birth and included 100 UK healthcare professionals.

IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cows’ milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is suitable for babies over 6 months as part of a mixed diet. 17-026 / June 2017

CONTENTS

COVER STORIES GUT HEALTH: 13 Improving children's diets 16 Fermented foods

News

Face to Face

Latest industry and product updates

41 ARFID Avoidant/restrictive food intake disorder

44 PROF BLOG The importance of vitamin D in our diet

With Clare Shaw, Consultant Dietitian

21 CHILDHOOD OBESITY An increasing worldwide problem 25 Oral nutritional supplements To prescribe or not to prescribe? 29 Plant sterols and stanols An overview

33 CYSTIC FYBROSIS

46 A day in the life of . . . Belinda Mortell, Registered Dietitian 48 Book review Sustainable Diets by

Mason and Lang

50 Web watch Online resources and updates

52 Event, courses and dieteticJOBS Dates for your diary and

Nutritional strategies and management

37 The dietetic virtual clinic Implementing a hospital service

job opportunities

53 The final helping A final farewell from Neil Donnelly

Copyright 2017. All rights reserved. NH Publishing Ltd. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst

Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk @NHDmagazine

www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

ISSN 2398-8754

www.NHDmag.com July 2017 - Issue 126

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.

We are looking to the future and pushing nutrition and dietetics to new places, which is both exciting and daunting at the same time. Embracing new ways of thinking and practising often feels like trying to put a man on the moon, but just remember this; on 20th July 1969, NASA did just that! Fermented foods have been used for thousands of years but have enjoyed a rebirth of late. Priya Tew takes a look their potential impact on gut health as part of our Cover Story this month, while Kate Roberts discusses current advice and recommendations for improving gut health in children. Continuing with a Paediatric theme, Priya also brings us insights in to a fairly recently recognised but common paediatric eating disorder, Avoidant/restrictive food intake disorder (ARFID). Often presenting in childhood before the age of 12 years, this has a significant impact on both physical and mental health of the child and on family life. Similarly, childhood obesity has just as much influence on family life and child health, Maeve Hanan RD gives us a comprehensive overview of the causes, consequences and government plans for addressing this widespread issue over the next 10 years. On 26th July 1978, Louise Brown was born, the first ‘test tube baby. A pioneering scientific development that paved the way for further success enjoyed by many couples with what we now know as ‘IVF’. New processes and techniques are often considered unbelievable or feared; however, there is always someone who has the passion and drive to take them on. Alice Lunt RD shares her experiences of implementing a virtual dietetic clinic within a hospital setting. Based in London, Alice takes us through the challenges and successes of

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setting up a virtual dietetic service based on ‘Telehealth’, a digital way to interact with patients within the hospital dietetic service. Could this be something coming to a dietetic service near you? In the early 1990s and before, who’d have thought that plant stanols and sterols had the potential to play a significant role in lowering cholesterol? However, since the mid-1990s they have been appearing in our supermarkets in various forms. Junee Sangani explains the current recommendations, gives a product overview and considers future research possibilities. In our NHD Extra digital supplement don’t miss Dr Lucy Aphramor’s insightful article which considers current public health messages and approaches. Lucy discusses effective methodologies within this avenue of healthcare, encouraging us to think differently and inspiring us all to embrace change. Although it is not a scientific discovery, another ‘first’ was revealed on 5th July 1946. The bikini was unveiled in Paris. Showgirl, Micheline Bernardini wore the first modern bikini and had the confidence to model this potential new trend. Back then, it caused an outrage, yet here we are in 2017, where it’s an essential part of the holiday wardrobe. Whether it is wearing your bikini or taking new directions in practice, go forth and we’ll be right there with you. Emma.

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

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

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

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.

Free school meals - in or out? School meals can create a friendly environment for children when eating their food with friends and teachers. These meals can also help to give children real, homemade foods without ultra-processed snacks creeping in, as is often the case in lunch boxes. Children also tend to bounce off each other and one kid’s ‘super healthy’ lunchbox may not be the norm amongst the abundance of crisps and sweet treats that are typically seen. So, the Tory manifesto aims to end free lunches for all but the poorest children in the first three years of school and then include free breakfasts instead. Will this really work? Possibly not, as many schools do not have the staff to serve breakfasts and in some instances this could even result in children having ‘two’ breakfasts. Breakfast is also probably likely to consist of refined, sugary cereals, as there is unlikely to be a budget available for more than this. This is a shame, as free school meals are now beginning to get established and show benefit. Also, surely, only offering free school meals to the poorest also ‘segregates’ them from the other children? The Tory plan: • Free school lunches will remain for those who need them. Free school lunches are not being scrapped - they are being means tested to make sure that free lunches go to those children whose parents can't afford it. • The changes will only affect better off parents and that money will be used for schools instead. • The most disadvantaged children will get two free school meals a day rather than one. The Tories say they will make sure that all those who need it most still get free lunches - and will offer a free school breakfast to every child in every year of primary school. So, it seems that the emphasis shifts to ‘better off’ parents having to provide healthy lunches. To me, the value of providing school meals is really about providing consistency amongst what children are eating - for them all to have the same opportunity and equal access to healthy and nutritious foods. These policies seem to segregate children and are likely to lead to an influx of less healthy lunchboxes again. For further information, see: www.conservatives.com/freeschoolmeals?gclid=CM6wodetptQCFYEaGwod47YLpw; www.theguardian.com/education/2017/may/19/jamie-oliver-condemns-theresa-may-for-scrapping-free-lunches www.theguardian.com/society/2016/sep/06/kids-school-lunchboxes-junk-food-research-england

If you are a student of Nutrition and Dietetics and would like to write an article for the NHD Student zone on our website, please email: info@networkhealthgroup.co.uk. Students are also eligible for a free subscription to NHD. See www.NHDmag.co.uk for more details. 6

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NEWS BREADS TO IMPROVE GLUCOSE RESPONSE Many of us eat bread on a daily basis. Now, new technologies used within the bread baking process have looked at how breads can be developed with a view to improving blood glucose response. A new study published in The British Journal of Nutrition has examined how different bread processing techniques, from mixing, proofing and freezing, can alter the glucose and insulin response to bread. From this work, scientists found that using ‘sourdough fermentation’ instead of the usual leavening process with yeast could help to lower the effect of postprandial insulin response. Further research is now needed. For more information, see: Stamataki NS et al (2017). British Journal of Nutrition. Vol 117, no 7; pg 1001-12.

TODDLER FOOD NEEDS WORK Snack foods amongst toddlers seem to require ongoing innovation and development. Presently, there is an abundance of sweet treats available, with these often being used to ‘treat’, or ‘bribe’ children, or gain the likeability factor. There seems to be some ‘joy’ in giving children unhealthy treats. It appears that work needs to be done when it comes to what we feed our toddlers as main meals. For example, a new study published in The American Journal of Clinical Nutrition found that 84% of toddler meals and 69% of savoury snacks aimed at toddlers contained high levels of sodium. Furthermore, more than 70% of toddler meals, cereal bars and breakfast pastries, grain or dairy-based desserts contained several sources of added sugar. So, it seems that more work is needed both when it comes to formulating foods aimed at toddlers and parental awareness of what they are actually feeding their young children. For more information, see: Maalouf J et al (2017). American Journal of Clinical Nutrition. [Epub ahead of print].

ESTIMATING BODY FAT LEVELS IN CHILDREN AND TEENS Obesity is an ongoing problem globally esp- Now, new research published in The Journal ecially amongst children and teens. Presently, of the American Medical Association has the most common and basic method for introduced as new method known as the ‘triscreening is the body mass index (BMI) using ponderal mass index (TMI)’. This is thought weight in kilograms divided by height in to estimate body fat levels in teenagers more metres squared. This is used worldwide to accurately than BMI, using the equation weight screen whether or not a person is overweight in kilograms divided by height in metres cubed. or obese. The TMI method appears to show promise, During the teenage years weight tends especially when used on non-Hispanic white not to be proportionate to height. For these children and teens. Further extended studies on reasons weight-adjusted age and gender ‘BMI other racial or ethnic groups are now needed to z-scores’ have tended to be used, yet the confirm the validity of TMI as universal method. BMI z-score has had its own problems and For more information, see: Peterson CM et al (2017). JAMA inaccuracies. Pediatr [Epub ahead of print]. www.NHDmag.com July 2017 - Issue 126

F2F

FACE TO FACE Ursula meets:

Ursula meets amazing people who influence nutrition policies and practices in the UK.

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.

CLARE SHAW Consultant dietitian: The Royal Marsden Hospital Author: Royal Marsden Cancer Cookery Book

If you do not come across cancer personally or professionally, it will enter your life regardless. It could be a degree removed via friends and family, or several degrees removed via tales of famous celebrities or tragic heroes. It might even be further removed via fictional description: Breaking Bad and The Fault in our Stars both engaged millions of people with the themes of battling cancer. “Working in the field of oncology is not for everyone,” concedes Dr Clare Shaw. But having worked as an oncology dietitian at Britain’s most specialist oncology hospital for more than 30 years, it seems to be just the job for her. Clare presented the British Dietetic Association annual Elsie Widdowson memorial lecture in 2016. This is viewable via www.bda.uk.com/ events, and is a moving description of her career in oncology. The unexpected and delightful insert in the lecture is a photo of supreme Elsie next to the young schoolgirl Clare: a picture that captured two great passions for nutrition: past and future. As a 14-year-old, she had been lucky enough to spend a day observing the dietetic work practices of our own NHD Final Helpings columnist, Neil Donnelly. This allowed the move from a ‘perhaps’ to a ‘definite’, about a career in Dietetics. During later school days,

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her teachers were not familiar with the A-Level combinations of chemistry and home economics, but Clare was fated by her name: she was sure. She entered a food and nutrition competition funded by Kraft Foods, and winning allowed her the meet-Elsie moment. “I didn’t really know much about Elsie, as this was a pre-Google time, but I was so impressed that she was so enthusiastic about nutrition research,” says Clare. She completed her dietetic degree at Queen Elizabeth College (now Kings College, London) and graduated in 1984. She started her career as a basic grade dietitian at Barts hospital and became involved in her first oncology cases. After 18 months, she moved on to take a one-year post at The Royal Marsden (and has never left). Her boss was concerned that she was becoming too specialist too quickly: it would be harder to move into other dietetic specialities later, but again Clare was sure. Of course, a 30-year career at the Royal Marsden means that you will have witnessed every kind of cancer and every kind of therapy. Clare enjoyed being part of research teams and first contributed to a trial examining possible effects of very low fat diets on hormone levels associated with breast cancer risk (= no benefit). Bitten by the research bug, she signedup to do a PhD at Kings College under

Of course, a 30-year career at the Royal Marsden means that you will have witnessed every kind of cancer and every kind of therapy. Professor Pat Judd. This was in addition to a full-time job! “It was harder and took longer than planned,” she confessed. But by 2003, she had a doctorate and could claim expertise in the beneficial effects of weight loss in the treatment of lymphedema. Clare has come to value critical questioning of practice and thinks all dietitians should self-audit their effectiveness. Importantly, the ‘so what’ hurdle should be put against any research proposals. “I think that the role of nutrition has become more and more important over the last 30 years. This is because many aspects of treatment, other than the cancer itself, affect nutrition status. Treatments have become better and more targeted and survival periods are now much longer. But it can also mean longer periods where feeding is affected and may need to be modified or supported,” says Clare. Her areas of specialism are late effects gastro function, particularly related to bile acid malabsorption, and she leads the parenteral nutrition team. She continues to attend outpatient clinics. And guides several candidates undertaking MSc and PhD projects. And guides future leaders undertaking the Darzi fellowships on clinical leadership at the Marsden. “Oncology did not used to be a dietetic specialism,” says Clare. “The oncology group of the BDA started with seven members; now there are 360. Longer survivorship means longer periods of time where dietetic care can make a big difference to health, and more dietitians are really needed to support community-based

oncology care.” Clare corrects my use of the word ‘patients’: it is ‘person with cancer’. And we laugh that a few years back the term ‘invalid’ was the common term (it so shrieks in-valid: how could this not be offensive?). In any case, I wonder how Clare deals with the constant challenging nutrition therapies and treatments being offered to people with a cancer diagnosis? Some cures are extreme and bizarre; others more moderate, advising single food elimination, but still advocating changes to normal meal patterns and food choices. Clare advocates always being open to dialogue and discussion on such topics. Elimination of dairy products is sometimes chosen after the diagnosis of breast cancer; although there is no evidence of benefit, this is easier today when various calcium-fortified milk-alternative products are widely available. Currently popular are ‘sugar free’ diets, but even here there is confusion: for some people this means no refined sugar added to tea or cereal; for others it means very low intakes of all carbohydrate foods – sometimes ketogenic diets. There is no evidence to support extreme diets as beneficial after cancer diagnosis, and dietetic advice means supporting food choices that offer best possible nutrition status while allowing for beliefs and preferences. Motivational interviewing (rather than just issuing food lists which may have been former practice) is now an essential part of dietetic practice.

If you would like to suggest a F2F date

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

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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.

WHAT TO LOOK FOR IN A PROBIOTIC A guide for healthcare professionals CHECK THE LABEL AND QUALITY

Does the label state the full strain name of the microorganism(s) in the product?

Does the label state the number of live cells of the probiotic strain(s) in the product?

NOTE: This should comprise three components: genus, species and strain identiﬁer.

Yakult contains 1010 Lactobacillus casei Shirota per 100 ml, when refrigerated.

Genus (e.g. Lactobacillus), species (e.g. casei) and strain (e.g. Shirota) is stated in full on Yakult’s packaging.

This is equivalent to 6.5 billion live cells per 65ml bottle.

Contact the company. Are there quality control procedures in place? NOTE: This is necessary to ensure the product contains the correct strains and number of live microbial cells as stated on the label.

Yakult is acknowledged by experts to be a quality probiotic.

CHECK THE SCIENTIFIC EVIDENCE

Contact the company or access their HCP website, to ﬁnd the supporting research. NOTE: (i) Regulatory restrictions mean companies can share research information with HCPs but not the general public; (ii) Not all probiotic research papers can be found on medical literature databases.

The research evidence for Lactobacillus casei Shirota can be found at www.yakult.co.uk/hcp or by contacting science@yakult.co.uk

CHECK FOR GI TRACT SURVIVAL

CHECK FOR EFFICACY OF THE STRAIN

For oral probiotics, are there human intervention trials showing survival of the probiotic strain(s) through the gut?

Check for trials and studies for the probiotic and the particular patient problem

NOTE : In vitro or model studies are not proof of gut survival in vivo.

(important for assessment of safety).

There are several research papers describing human studies showing the gut survival of Lactobacillus casei Shirota.

See expert advice in ‘LcS Insight: HCP Study Day 2014’ and ‘Your Guide to Probiotics’.

For further support on what to look for in a probiotic or to access the research behind Yakult, then please visit www.yakult.co.uk/hcp contact science@yakult.co.uk or call 020 8842 7600 This resource is intended for healthcare professionals. Not to be distributed to patients.

COVER STORY: GUT HEALTH

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

IMPROVING GUT HEALTH IN CHILDREN THROUGH DIET We all know that gut health is incredibly important for general health. Research has connected microbial imbalance, or dysbiosis, with many unwanted health outcomes, including multiple sclerosis, diabetes and autism.1 It is, therefore, important to provide childrenâ&#x20AC;&#x2122;s guts with good bacteria and food for that bacteria to give them a chance to develop a healthy microbiome. However, evidence is pretty thin with what advice we can give in the UK. So what can we recommend? We as health professionals should not forget the basics when it comes to recommending any kind of health promotion. The Mediterranean Diet, as well as all the other benefits, promotes a healthy gut (see Figure 2 overleaf).2 It seems that increasing the proportion of plant-based foods into diets including lots of vegetables, fruit, nuts, seeds and wholegrain carbohydrates improves gut health in association with the other wellknown benefits of disease reduction. However, it is always important in Paediatrics to consider the child. Excess fibre can cause loose bowels and plantbased diets can be low in energy, iron and B12 if not managed properly. When recommending changes in diet, ensure that all vital nutrients for growth and development are available and that the childâ&#x20AC;&#x2122;s weight, growth and symptoms are monitored regularly. PREBIOTICS

Prebiotics are often overlooked, but they are vital for gut health. Prebiotics are certain carbohydrates called oligosaccharides which are indigestible, they ferment in the large intestine and produce short chain

fatty acids. They, along with dietary fibre, provide the substrate that probiotics feed on in the gut.3,4 Following the Mediterranean Diet has been directly associated with an increase in short chain fatty acids in faeces. The beneficial effects were seen in omnivores as well as vegetarians and vegans.2 Child friendly foods that have a high content of prebiotics include apples, oats, leeks, onions, garlic, linseed and wheat bran. It is questionable whether we need to encourage specific prebiotic containing foods if children are having a diet which is high in fruit, vegetables, legumes and whole grains.3 PROBIOTICS

Here are some examples of food and drink that contain good bacteria which can be given to children: â&#x20AC;˘ Yoghurt is an excellent and economical source. Certain yoghurts aimed at children do have live bacteria present, but we should encourage parents and carers to look at labels. A cheaper option is to get large containers of live yoghurt to serve, fruit can be added if children do not like plain. Full fat versions are available and contain less sugar. Dairy free versions are available including soya and coconut. Again, ask parents and carers to check the labels as they need to have bacteria in the ingredients list. www.NHDmag.com July 2017 - Issue 126

GUT HEALTH Figure 1: Mediterranean Diet Pyramid

source: www.mediterradiet.org/nutrition/mediterranean_diet_pyramid

• Actimel produces probiotic drinks specifically for children aged three and up which contains two strains of Lactobacilli. It is unclear how many are contained from information given. Actimel contains 11.2g of sugars per serving (100g). • Fermented drinks such as kefir and kombucha are suitable for children, these can be homemade. They do need special equipment. They can be purchased but are expensive. • Other fermented foods include miso, sauerkraut, kimchi, and lacto-fermented vegetables such as pickles. A lot of bought versions in mainstream shops will no longer be live. It is possible to make them at home. It may be tricky to get older or picky children to accept foods such as these. Also remember that many of these foods have a high sodium content. Always remember that fermented food needs to be introduced gradually, large portions too fast could cause nasty symptoms. Please see Priya Tew’s article on fermented foods on pages 16-19 in this issue for more information. 14

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ARE THERE FOODS TO AVOID?

Diet is known to effect the microbiome and changes occur swiftly. Diets which are high in fat and sugar have been shown to negatively affect microbes present.5 It has also been reported by some ‘health experts’ that processed food disrupts gut microbiota. The term ‘processed’ is very vague and can refer simply to cooking or freezing. The only evidence for this is in a study which looked at the effect of dietary emulsifiers on the gut bacteria of mice.6 It did effect the gut mucosa; however, I’m not sure how easy it is to find if foods contain carboxymethylcellulose or polysorbate-80 and whether this would have the same affects in humans. Therefore, encouraging healthy eating and nudging people away from high fat and high sugar foods is better than demonising any specific foods. SUPPLEMENTS

There are many probiotics for sale which are marketed for children including capsules, chewy tablets and even chocolate. They are available

GUT HEALTH

. . . it is best to recommend that children are eating healthily based on the Mediterranean Diet, including plenty of vegetables, legumes, fruit and wholegrains . . . online and in health and wellness shops. There is no firm evidence for health professionals to recommend any in particular for general gut health. There are hundreds of different strains of each bacteria within different classes of probiotics such as Lactobacilli and Bifidobacteria. There has been evidence that providing certain strains of probiotics can help specific problems. For example, providing certain probiotics to children taking antibiotics can reduce the risk of antibiotic-associated diarrhoea.7 It may be that we have to wait for individual stool analysis to be less expensive, more reliable and widely available before dietitians and other

healthcare professionals can recommend specific strains with confidence. CONCLUSION

In summary, it is best to recommend that children are eating healthily based on the Mediterranean Diet, including plenty of vegetables, legumes, fruit and wholegrains and reducing high fat and high sugar foods where possible. This should cover the prebiotics needed to provide nutrition for any probiotics consumed. Increasing probiotic foods daily is a good aim, but remember to consider the familyâ&#x20AC;&#x2122;s situation in terms of time, skills and money available. A live yoghurt daily is better than nothing.

References 1 Jason Lloyd-Price, Galeb Abu-Ali and Curtis Huttenhower. The healthy human microbiome. Genome Medicine (2016) 8:51 DOI 10.1186/ s13073-016-0307-y 2 De Filippis F, Pellegrini N, Vannini L, et al. High-level adherence to a Mediterranean diet beneficially impacts the gut microbiota and associated metabolome. Gut 2016;65:1812-1821 3 Blaut M. Relationship of prebiotics and food to intestinal microflora. EurJNutr41 [Suppl1] (2002):I/11â&#x20AC;&#x201C;I/16. DOI 10.1007/s00394-002-1102-7 4 Cummings JH, Macfarlane GT and Englyst HN. Prebiotic digestion and fermentation. February 2001, vol 73, no 2, 415s-420s 5 Tilg H and Kaser A. Gut microbiome, obesity, and metabolic dysfunction. J Clin Invest. 2011;121(6) :2126-2132. doi:10.1172/JCI58109 6 Chassaing B et al. Dietary emulsifiers impact the mouse gut microbiota promoting colitis and metabolic syndrome. Nature. 2015 Mar 5; 519 (7541): 92-96. doi:10.1038/nature14232 7 Brian S Alper, Monica Zangwill, James LaRue, Eric W. Manheimer (2017). Evidence for clinical practice - Do probiotics reduce the risk of antibioticassociated diarrhoea (AAD) in children taking antibiotics? European Journal of Integrative Medicine Volume 12, June 2017, Pages 129-130

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GUT HEALTH: FERMENTED FOODS

FERMENTED FOODS, IBS AND THE MICROBIOME Priya Tew Freelance Dietitian

The gut microbiome contains 10 times more microbial cells than all the human cells in the body.2 It is a vast and diverse array of bacteria, arachea, viruses and unicellular eukaryotes.

Priya runs Dietitian UK, a freelance dietetic service that specialises in eating disorder support. She works with NHS services, The Priory Hospital group and private clinics. Priya also provides Skype support to clients nationwide.

Firmicites and Bacteroidetes (gramnegative) and Actinobacteria (grampositive) make up 90% of the bacteria in the gut, the most abundant site being the colon.2 Although there are more than 1,000 species of bacteria that could be present, it is estimated that only 150-170 predominate in a person.3 HOW DOES THE BALANCE OF BACTERIA AFFECT THE MICROBIOME AND THUS HEALTH?

• Gut barrier integrity - bacteria can increase tight junctions and decrease permeability, so decreasing the leakage of endotoxins into the bloodstream.1 • Immunity maintenance - the right balance of micro-organisms can suppress pathogens, suppress proinflammatory factors and stimulate immune cell proliferation.1 • Fermentation by-products Humans lack the enzymes to digest fully the bulk of dietary fibre, so these pass into the large intestine for fermentation. The major group of by-products are short chain fatty acids (SCFA) of which acetate, propionate and butyrate are the most abundant.2 The right balance of bacteria can lead to by-products that decrease luminal pH, inhibit pathogen growth, simulate mucin production and the production of immune fighting cytokines.1 • Direct competition for nutrients - resulting in pathogenic bacteria decreasing in numbers.4 16

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PREBIOTICS AND PROBIOTICS

Prebiotics are substrates that provide a health benefit by selectively promoting the growth of beneficial bacteria in the intestine.6 Probiotics are ‘live microorganisms which when administered in adequate amounts confer a health benefit on the host.’ World Health Organisation (WHO).7 Prebiotics and probiotics are bacteria that can affect the balance of the microbiota; they are beneficial to health and could affect disease states. There are many probiotics on the market and so this has become another area of confusion. Who benefits from taking a probiotic and which one is the best choice? When advising a patient to take probiotics, it makes sense to choose one which is appropriate for their symptoms, rather than giving general “take a probiotic” advice. Probiotics are also rapidly evolving and, as we learn more about the microbiome, they are likely to become more specific. When trying a probiotic, it is advisable to take it daily in adequate amounts for one month and monitor symptoms.6 This is currently a hot topic of research, with probiotics being incorporated into an array of foods, drinks, supplements and pharmaceutical products. Probiotic drinks are one of the fastest growing industry segments and are big business. However, as with many heath products, some are better than others. It is important to look at the specific bacterial strain being used in the probiotic and check this has evidence. A good place to look for a summary is the World Health Organisation (WHO)

Probiotic drinks are one of the fastest growing industry segments and are big business. However, as with many heath products, some are better than others.

Lactobacillus bulgaricus bacteria Table 1: Summary of bacterial strains and dosage7 L.plantarum

5 x 107 CFU billion once daily

improvement in abdominal pain

E.coli

107 CFU three times daily

L.rhamnosus, L plantarum, L. acidophilus and E.foecium

10 billion bacteria

improvement in IBS score

B.coagulans and fructo-oligo saccharides

15 x 107 three times daily

Decreases pain, improves constipation

L.animalis subsp, lactise BB-12, L.acidophilus, L.delbruekii subsp, bulgaricus, Strept thermophilus

4 billion CFU twice daily

Improvement in pain and bloating

Sacc.boulardii

109 CFU of 250mg twice daily

Improvement in IBS QOL score

Bifido.animalis in fermented milk with (Strept thermophilus and L.bulgaris)

1010 CFU twice daily

Improvement in global assessment of IBS symptoms

L.acidophilus

1010 CFU once daily

Improvement in HRQOL in IBS-C

L.rhamnosus, Propionbacterium freudemreichii, shermanii, Bifido animalis subsp. lactis

1010 CFU once daily

Short chain fructo-oligo saccharides

5g daily

Galacto-oligosaccharide

3.5g daily

B.coagulans

2 x 109 CFU once daily

Table adapted from WHO Global Guidelines

www.NHDmag.com July 2017 - Issue 126

Sauerkraut, kimchi, dry fermented sausage, live yoghurt, cheeses, kombucha and miso are other examples of fermented foods

Gastroenterology Guidelines (Table 1).7 This shows that different formulations need to be taken at differing amounts and frequencies. Some, such as Bacillus coagulans, need to be taken three times daily while others are taken once daily. Popular UK formulations include OptiBac containing Saccharomyces boulardii, a yeast with some benefits in IBS-D and in improving quality of life scores. Alflorex contains a live culture and is suitable on a low FODMAP diet. Symprove contains a good range of the bacteria (including L.Rhamnouose, E.faecium, L.acidophils and L.plantarum), noted as helpful in the research studies. Educating patients to take the right strain at the right dosage for the right length of time is, therefore, important. IBS

IBS is one of the most common intestinal disorders in the industrial world, affecting 1015% of the population.5 The research shows that IBS-C and IBS-D patients have different types of microbes that predominate and that alterations in gut microbiota may be a cause or a consequence of altered gut symptoms. A systematic review of 37 studies on mainly IBS (but 10 antibiotic-associated) diarrhoea cases showed that specific probiotics help to reduce symptoms and pain in some IBS-D patients.6 This worked out as five studies on a total of 1,313 patients with IBS, taking five different strains of probiotics. The review found a significantly 18

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beneficial effect against placebo, with three studies showing no effect. The probiotics used in the studies predominantly contained lactobacilli and/or bifidobacteria, a few were Saccharaomyces. 18 studies of 15 probiotics looked at abdominal pain in 1,806 patients with IBS, with a high agreement of evidence, suggesting that there was a reduction in pain scores. Bowel habits (urgency, incomplete evacuation and frequency) were found to be moderately improved with probiotics. A moderate effect was seen on bloating and no effect on wind. Looking specifically at 152 patients with IBS-D, there was very low evidence for any probiotic effect, with some patients even reporting a worsening of diarrhoea symptoms. There was also little evidence for any effect on IBS-C, so more research is needed in this area.6,7 It may be that prebiotics are more helpful than probiotics for constipation dominant IBS, or that the right research is yet to be conducted in this area. WHAT WE EAT CAN ALTER OUR GUT MICROBIOME

Fermented foods are seeing a resurgence in Western countries. These are foods that are made through controlled microbial growth and the enzymatic conversion of food components in a natural process.10 Although there are thousands of these foods around the world, industrialisation has decreased the range eaten frequently in Western diets. As the health benefits of these

GUT HEALTH: FERMENTED FOODS foods become a media focus, they are likely to increase in popularity. Fermentation changes the taste profile of a food and lowers the pH which prevents contamination by potential pathogens.7 Fermentation can also remove toxins such as phytic acid from cereals and can make some foods more tolerable, such as reducing the FODMAPs in sourdough bread. Studies show benefits of fermented foods on weight maintenance, Type 2 diabetes, CVD, obesity and more.6,8,9 EXAMPLES OF FERMENTED FOODS

Milk based One of the most common is Kefir. This contains yeast and a range of different bacteria which can differ depending on the environment it is made in and the culture used. Drinkable yoghurts are popular and have some research to back up their health claims, but it is worth checking the strain of bacteria added to these against the evidence. Water based For those preferring a non-milk option, or who have a cows’ milk protein allergy/lactose

intolerance/vegan diet, there are probiotic waters made using kefir grains. Live Kombucha soda is a fizzy brew with <0.5% alcohol content, but with very little research to back up its use. Foods Sauerkraut, kimchi, dry fermented sausage, live yoghurt, cheeses, kombucha and miso are other examples of fermented foods that are on the rise in popularity. Some of these products, such as Kefir milk and water, are easy to make at home. Making and eating fermented foods could help to introduce new microbes into the body and be a cheaper alternative to buying a pharmaceutical formulation. However, it can be difficult to know what species of bacteria the food products contain and there is very little research currently to show how they affect the microbiome. The potential is there, but they are unlikely to make long lasting effects unless taken daily and more research is definitely needed before dietitians can use these foods as specific probiotic treatments. They could, however, be used as an addition to any products taken.

References 1 PEN Nutrition: Gastrointestinal System - Microbiota 2 Ho JT et al (2015). Systemic effects of gut microbiota and its relationship with disease and modulation. BMC Immunol 16:21 3 Kate Scarlata http://blog.katescarlata.com/2014/10/27/probiotics/ 4 Kim D et al (2016). Gut microbiota in autoimmunity: potential for clinical applications. Arch Pharm Res. 39(11): 1565-1576 5 Sanders ME et al (2013). An update on the use and investigation of probiotics in health and disease. Gut. 62(5): 787-96 6 Hungin APS et al (2013). Systematic review: probiotics in the management of lower gastrointestinal symptoms in clinical practice - an evidence-based international guide. Aliment Pharmacol Ther. 38(8): 864-886 7 World Gastroenterology Organisation Global Guidelines: Probiotics and Prebiotics. February 2017. www.worldgastroenterology.org/guidelines/ global-guidelines/probiotics-and-prebiotics/probiotics-and-prebiotics-english 8 Cani PD et al (2007). Metabolic endotoxemia initiates obesity and insulin resistance. Diabetes. 56:1761-72 9 Den Besten G et al (2013). The role of short chain fatty acids in the interplay between diet, gut microbiota and host energy metabolism. J Lipid Res. 54:2325-40 10 FAO/WHO Working Group. London, Ontario, Canada (2002). Guidelines for the evaluation of probiotics in food. Report of a joint FAO/WHO working group on drafting guidelines for the evaluation of probiotics in food. Available at: ftp://ftp.fao.org/es/esn/food/wgreport2.pdf

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PAEDIATRIC

CHILDHOOD OBESITY Maeve Hanan Registered Dietitian, City Hospitals Sunderland

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.

Childhood obesity is becoming an increasingly worrying issue.1 In 2014, an estimated 41 million children worldwide under the age of five were either overweight or obese1 and UK figures from 2015 revealed that almost a third of all children were overweight or obese.2 It may be surprising that, in absolute figures, there is more childhood obesity in developing countries compared to high-income countries; for example, in Africa 10.3 million children are classed as overweight or obese, which has almost doubled in the past 25 years.1 There is also an economic motivation for tackling this issue as it is estimated that the NHS in England spends roughly ÂŁ5 billion per year on treating conditions related to obesity.3 POTENTIAL CONSEQUENCES

Endocrine disorders Childhood obesity has been shown to increase the risk of developing diabetes as an adult more than adultonset obesity does.9 Furthermore, children as young as seven have been diagnosed with Type 2 diabetes in the UK.4,6 UK data also shows that 95% of children diagnosed with Type 2 diabetes were overweight and 83% were obese, 7 which is supported by similar data from the US.8 Premature puberty is also associated with childhood overweight and obesity, which can impact on growth and behaviour.

Respiratory disorders A recent systematic review found a 40-50% increased risk of asthma in children who are overweight or obese.10 Specifically, a rapid increase in BMI in the first two years of life is associated with an increased risk of developing childhood asthma11 and a higher BMI may be associated with a more severe form of asthma.12 Research suggests that obstructive sleep apnoea rates may be as high as 60% in obese children and adolescents.13 Overweight and obesity can also reduce exercise tolerance and increase fatigue levels. Cardiovascular disorders As well as increasing the risk of developing cardiovascular disease in adulthood, childhood obesity can result in cardiovascular damage in childhood.14 Studies have found that 62-70% of those with childhood obesity present with cardiovascular risk factors such as hyperlipidaemia and hypertension.15-16. A study from the US reported that children in the obese category had a fourfold increased risk of developing hypertension as an adult.17 Musculoskeletal disorders Overweight and obesity can add excess pressure to the musculoskeletal system www.NHDmag.com July 2017 - Issue 126

PAEDIATRIC Figure 1: Prevalence of excess weight among children

which can result in Blount’s disease (where the lower leg becomes bow-shaped due to interference with the tibial growth plate), hip disorders, back pain, knee pain, ankle and foot issues and more restricted activity levels.4

Worryingly, it has also been reported that obesity can double the risk of premature death,3 which could potentially take three to seven years off an obese adult’s life.5

Gastro-intestinal disorders Childhood obesity can increase the risk of developing non-alcoholic steatohepatitis (NASH), where fat can accumulate in the liver causing inflammation and damage.5

There is ongoing research into the numerous factors which contribute to obesity; but, overall, this is a complex area. Energy imbalance is an important part of this picture, but there is ongoing research into areas such as physiological, gastrointestinal, hormonal and metabolic risk factors. The obesogenic environment has a big role in encouraging an energy imbalance, with the increased availability of cheap high energy foods and an increasingly sedentary lifestyle; which often includes a lot of ‘screen time’ when it comes to childhood obesity.1 Genetic and epigenetic responses have an impact on childhood obesity risk, as maternal malnutrition and undernutrition in early childhood have been shown to increase the risk of obesity in later life. Conversely, maternal and paternal obesity can also increase the risk of childhood obesity.1 In developed countries, the highest risk of childhood obesity in seen in lower socioeconomic groups and also within minority

Psychological issues Evidence shows an increased risk of: low selfesteem, reduced quality of life, behavioural issues, poor social skills, being bullied, body image dissatisfaction and eating disorders in children and adolescents who are in the obese weight category.4,18-19 These issues may contribute to the observed association between childhood obesity and reduced educational attainment.1 Chronic diseases in adulthood Childhood obesity often leads to adult obesity and related chronic conditions1 such as: heart disease, stroke, Type 2 diabetes, dementia, certain cancers (e.g. breast, colon, endometrial) and liver disease.1,5,20 22

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CAUSES OF CHILDHOOD OBESITY

Table 1: Summary of the UK Government Childhood Obesity Plan Soft drinks industry levy

Producers and importers of sugary drinks have two years to lower the amount of sugar in their products, otherwise they will face an increased levy.

20% reduction in sugar content of products

Challenging the food and drinks industry to reduce the sugar in products frequently consumed by children (e.g. breakfast cereals, yoghurts, cakes, biscuits, confectionery) by 5% in year one and 20% by 2020.

Support research and innovation

Working with Innovate UK, the Agri-Food Technology Council and the Food Innovation Network to create healthier products.

Updating the nutrient profile model

Products have a score to represent how healthy they are which affects what foods can be advertised to children. However, these need to be updated to represent the current evidence base.

Healthy options in public sector settings

Setting an example in all public sector buildings (e.g. schools, hospitals, leisure centres, etc) by providing healthy food options and restricting junk food.

Supporting the cost of healthy options where needed

Ongoing ‘Healthy Start’ scheme which provides vouchers for fruit, vegetables and milk to those who need financial support.

Encouraging an hour of physical activity per day for all children

Every primary school child should get at least 30 minutes of physical activity in school via ‘active break times, PE, extra-curricular clubs, active lessons or other sport and physical activity events’. The remaining 30 minutes should be provided outside of school.

Improving sport and physical activity programmes in schools

All primary schools in England should have access to good quality local and national sport and physical activity programmes.

Creating a healthy rating scheme for primary schools

A voluntary scheme for primary schools to be introduced in September 2017 to encourage healthier eating and physical activity.

Making school food healthier

Encouraging all schools, including academies to commit to new UK School Foods Standards (2015) and £10 million per year from the soft drinks levy to be used to support healthy breakfast clubs.

Clearer food labelling

Potentially distinguishing between the types of sugar in products to support healthier choices.

Supporting Early Years settings

Revised voluntary guidelines for menus in Early Years settings by the Children’s Food Trust.

Harnessing new technology

For example: Change4Life Sugar Smart app and digital innovations from Public Health England.

Health professionals to support families

Making ‘Every Contact Count’ with conversations on behaviour change, referrals for weight management support and signposting to reliable websites and resources.

groups who may be at risk of poor interaction with the health care system.1 For example, in the UK, children from the lowest income groups have double the risk of becoming obese compared to children from more affluent areas.3 However, the opposite is true in the developing world where higher obesity rates are seen in wealthier population groups; which may be related to the loss of traditional diets.1 The way society interacts with obesity can also exacerbate this issue; as the perceived

normalisation of obesity can reduce an individual’s motivation to make changes,1 but equally, the stigmatisation of obesity can hinder behaviour change due to psychological processes, especially when it comes to issues such as emotional eating and binge eating. REDUCING CHILDHOOD OBESITY

It is often discussed that ‘no single intervention will cure childhood obesity’ due to its complex background as discussed above. For this reason, www.NHDmag.com July 2017 - Issue 126

PAEDIATRIC Figure 2: Ending childhood obesity - recommendations from WHO

the World Health Organisation (WHO) have formed a ‘Commission on Ending Childhood Obesity’ which highlights the responsibility of all stakeholders (i.e. WHO, international organisations, national governments, NGOs, the private sector, charitable organisations and universities) in reducing the risk of childhood obesity to improve health and health equity worldwide.1 The main areas WHO has recommended to target are highlighted in Figure 2.

The UK government’s response to this call for action was the 2016 childhood obesity strategy which aims to reduce the rate of childhood obesity in England over the next 10 years.3 This has received a lot of criticism for being too weak in its proposals and the document itself states that ‘the launch of this plan represents the start of a conversation, rather than the final word’. The main points of the UK’s ‘Childhood Obesity: A Plan for Action’ are summarised in Table 1. From my experience of working in a childhood weight management setting, I feel that the way we interact with children and their families is key, especially ensuring that we focus on the positives, set realistic goals, boost the children’s self-esteem as much as possible and focus on ‘healthy choices’ and moderation rather than obsessing over a ‘healthy weight’. It can also be useful to highlight the benefits of healthy changes without mentioning weight; for example, explaining the benefits of a healthy diet regardless of weight, or how physical activity is associated with healthy bones and joints, improved fitness, improved mood, better sleep and improved academic performance.3 CONCLUSION

Childhood obesity is evidently a crucial and topical issue worldwide which has far-reaching implications. Hopefully, in the next 10 years we will see an improvement in the prevalence of childhood obesity, but for this to happen large scale changes and cooperation between all key players is urgently needed.

References 1 World Health Organisation (2016). Report of the Commission on Ending Childhood Obesity (available at: http://apps.who.int/iris/ bitstream/10665/204176/1/9789241510066_eng.pdf) 2 Health and Social Care Information Centre (2015). Health Survey for England 2014 3 HM government (2016). Childhood Obesity - A Plan for Action (available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/546588/Childhood_ obesity_2016__2__acc.pdf) 4 Public Health England (2017). Health risks of childhood obesity (available at: www.noo.org.uk/NOO_about_obesity/obesity_and_health/health_risk_child) 5 Childhood Obesity Foundation. What are the Complications of Childhood Obesity? (available at: http://childhoodobesityfoundation.ca/what-is-childhood-obesity/ complications-childhood-obesity/) 6 Diabetes UK (2012). Key Statistics on Diabetes 7 Richardson et al (2012). Timing and duration of obesity in relation to diabetes: findings from an ethnically diverse, nationally representative sample 8 Li et al (2009). Prevalence of pre-diabetes and its association with clustering of cardiometabolic risk factors and hyperinsulinemia among US adolescents 9 Haines et al (2007). Rising incidence of Type 2 diabetes in children in the UK 10 Egan et al (2013). Childhood body mass index and subsequent physician-diagnosed asthma: a systematic review and meta-analysis of prospective cohort studies 11 Rzehak et al (2013). Body mass index trajectory classes and incident asthma in childhood: results from eight European birth cohorts 12 Black et al (2013). Increased asthma risk and asthma-related healthcare complications associated with childhood obesity 13 Kang et al (2012). Body weight status and obstructive sleep apnea in children 14 Cote et al (2013). Childhood Obesity and Cardiovascular Dysfunction 15 Freedman et al (2007). Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study 16 Van Emmerik et al (2012). High cardiovascular risk in severely obese young children and adolescents 17 Watson et al (2013). Adult hypertension risk is more than quadrupled in obese children 18 Griffiths et al (2010). Self-esteem and quality of life in obese children and adolescents: a systematic review 19 Gatineau et al (2011). Is obesity associated with emotional and behavioural problems in children? 20 Pischon et al (2008). General and abdominal adiposity and risk of death in Europe

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COMMUNITY

Naomi Johnson Scientific and Regulatory Manager, BSNA

ORAL NUTRITIONAL SUPPLEMENTS (ONS): TO PRESCRIBE OR NOT TO PRESCRIBE?

IN ASSOCIATION WITH THE BSNA

The NHS was founded in 1948 with the ambition of bringing good healthcare to all, regardless of wealth. Whilst initially free on the NHS, prescription charges were introduced in 1952. Since then, the availability and cost of prescriptions has been an ongoing topic of change and debate.

Katherine Sykes Communications Consultant, BSNA

Naomi has a First Class Honours degree in Nutritional Science and an MSc in Public Health Nutrition. She has worked in the nutrition industry for several years. www.bsna.co.uk Katherine is a public affairs and strategic communications specialist, focusing on health and nutrition. Since 2005, she has worked both in-house and in consultancy.

NHS England and NICE guidance1 state that Oral Nutritional Supplements (ONS) should be prescribed whenever there is a clinical need to do so. The provision of ONS on prescription ensures that under the supervision of a healthcare professional, all patients, including the most vulnerable, are able to access the products that are most appropriate for their care, whenever they are needed. Which prescriptions are available in which area is dependent on each Clinical Commissioning Group (CCG), the clinically-led statutory bodies that are responsible for the planning and commissioning of health care services for their local area. Facing significant pressure to cut costs, some CCGs are limiting, or restricting, prescriptions of ONS - with health ramifications that are increasingly worrying. WHERE DO ONS FIT IN?

ONS are evidence-based nutritional solutions for disease-related malnutrition.2 These highly regulated products3 can partially, or wholly, replace a normal diet to provide patients with the essential nutrients they need when food alone is insufficient to meet their daily needs.4-6 The NICE Quality Standard on Nutrition Support in Adults (QS24)5 recognises that ONS are a clinically effective way to help manage disease-related malnutrition: ‘It is important that nutrition support goes beyond just providing sufficient calories and

looks to provide all the relevant nutrients that should be contained in a nutritionally complete diet. A management care plan aims to provide that and identifies condition specific circumstances and associated needs linked to nutrition support requirements.’ Healthcare professionals are best placed to evaluate whether patients need ONS and if so, for how long patients should be taking them. They can also provide patients with the most appropriate products for their individual clinical conditions and circumstances. ONS can play an essential part in medical management, acting as invaluable support when food alone is insufficient, either for short periods of time, or for life. Receiving timely ONS is essential to the prevention and management of malnutrition and patients should only be prescribed ONS when they cannot meet their daily nutritional requirements from food alone, and/or are at risk of malnutrition due to a disease, disorder, medical condition or surgical intervention. Combined with regular monitoring and review of patients’ individual needs and circumstances by a healthcare professional, as outlined in NICE Clinical Guideline 32,4 QS245 and the Managing Adult Malnutrition in the Community Pathway,6 this provides the most effective management solution for patients who are malnourished, or at risk of malnutrition. ONS should be discontinued when an individual is no www.NHDmag.com July 2017 - Issue 126

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COMMUNITY

The cost of malnutrition in England is estimated to be £19.6 billion per year, or more than 15% of the total public expenditure on health and social care. longer malnourished, has met their nutritional goal(s) and is able to meet their nutritional needs through food alone. COST-EFFECTIVENESS

The cost of malnutrition in England is estimated to be £19.6 billion per year, or more than 15% of the total public expenditure on health and social care.7 About half of this expenditure is on older people (>65 years). A British Association for Parenteral and Enteral Nutrition (BAPEN) report published in 2015 stated that ‘interventions with nutritional support (to implement the NICE clinical guidelines/ quality standard), including ONS, enteral tube feeding (ETF) and parenteral nutrition (PN) in hospital and community settings, were found to lead to greater net cost savings than those reported by NICE. The savings were even greater when the prevalence of malnutrition was high, when hospital admission rates were high, and when the gap between current care and desirable nutritional care was high.’ 7 From the BAPEN report, five different models, which

involved nutritional support in 85% of subjects with a high malnutrition risk, all resulted in cost savings. In a systematic review examining the cost and cost effectiveness of using standard ONS in the hospital setting, 12 of 14 cost analyses favoured the ONS group versus no ONS, and among those with quantitative data (12 studies), the mean cost saving was 12.2%.8 A meta-analysis showed a mean net cost saving of £746 per patient. Typically, cost savings were associated with significantly improved outcomes; reduced mortality (P < 0.05); reduced complications (P < 0.001); reduced length of hospital stays (by ~2 days, P <0.05) which corresponded to roughly a 13.0% reduction in hospital stays. ONS were also found to be cost effective by avoiding development of pressure ulcers and releasing hospital beds in one study and in another by gaining quality adjusted life years. A systematic review examining the cost and cost effectiveness of using ready-to-consume ONS in the community and care home setting demonstrated that ONS www.NHDmag.com July 2017 - Issue 126

COMMUNITY compared to no ONS or routine care produces an overall cost advantage, particularly when used for up to three months (median cost saving of 9.2%; P<0.01).9 A median cost saving of ~5% was found for ONS use of ≥3 months. Significant cost savings can be made through the use of ONS as part of a dietary management strategy. Implementing NICE CG32 and QS24 in 85% of patients at medium and high risk of malnutrition would lead to a net saving of £172.2-£229.2 million, which equates to £324,800 - £432,300 per 100,000 people.7 It costs more to treat a malnourished patient than one who is not malnourished.

recent systematic review, which analysed nine studies, found that ONS in the community reduced hospitalisation by 16.5% (P<0.001).9 With age, people naturally tend to eat less. Coupled with numerous variables, such as physiological changes, medications, illness and reduced mobility, it is very likely that shortfalls in micronutrients will arise. Such deficiencies associated with malnutrition can lead to an increased risk of falls, susceptibility to infections and confusion, for example, and result in increased hospital stays and social intervention. The malnourished are also at an increased risk of mortality.11,12

PREVENTION IS ALWAYS BETTER THAN CURE

Restrictions of ONS are of significant concern and are likely to affect patients’ long-term health outcomes. Although CCGs are under increasing pressure to cut costs, a blanket approach is unlikely to be appropriate for all patients in all circumstances. Ensuring the maintenance of nutritional status and thus reducing malnutrition and its associated co-morbidities should be higher up the health agenda. It is important to consider the long-term health and financial implications of malnutrition when looking at overall prescribed ONS expenditure. The provision of ONS on an FP10 prescription ensures that, under the supervision of a healthcare professional, all patients, including the most vulnerable, are able to access the ONS products that are most appropriate for their care, whenever they are needed.

The implications of malnutrition are not just to the health and social care bill, but, more importantly, to overall wellness and health outcomes. However, despite growing awareness of the implications of malnutrition, especially in the community setting, there continues to be a lack of support and acknowledgement of those most at risk. While weight loss and decline in health are aspects of aging, all too often we accept these changes as normal and fail to consider that ensuring sufficient nourishment could delay and diminish these issues, thus prolonging good health for as long as possible: maintenance of a good nutritional status can delay and reduce the risk of developing diseases, help maintain functional independence and, therefore, promote continued independent living.10 A

CONCLUSION

For more information and to download our information sheet on the value of ONS see: www.bsna.co.uk/uploads/files/BSNA_ONS-Document_Oct-2016.pdf References 1 NHS England Guidance on Commissioning Excellent Nutrition and Hydration 2015-2018. www.england.nhs.uk/wp-content/uploads/2015/10/nut-hyd-guid.pdf 2 Stratton RJ, Green C and Elia M (2003). Disease related malnutrition; an evidence-based approach to treatment. Oxford: CABI Publishing 3 EU Commission Delegated Regulation (EU) 2016/128 supplementing Regulation (EU) No 609/2013 4 National Institute for Health and Clinical Excellence (NICE). Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. 2006 www.nice.org.uk/guidance/cg32 5 NICE Quality Standard [QS24] Nutrition support in adults. National Institute for Clinical Excellence, 2012 6 Managing Adult Malnutrition in the Community. Including a pathway for the appropriate use of oral nutritional supplements (ONS). The Malnutrition Pathway produced by a multi-professional consensus panel, May 2012. http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf 7 Elia M (2015). The cost of malnutrition in England and potential cost savings from nutritional interventions. BAPEN and National Institute for Health Research (NIHRN). www.bapen.org.uk/pdfs/economic-report-short.pdf last accessed: 22 May, 2017 8 Elia M, Normand C, Norman K and Laviano A (2016) A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in the hospital setting. Clinical Nutrition 35:370-380 9 Elia M, Normand C, Norman K and Laviano A (2016). A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in community and care home settings. Clinical Nutrition 35:125-137 10 Wilma L and Hankey C (2015). Aging, Nutritional Status and Health. Healthcare 3:648-658 11 Margetts BM, Thompson RL, Elia M and Jackson AA (2003). Prevalence of risk of undernutrition is associated with poor health status in older people in the UK. Eur. J. Clin. Nutr. 57, 69-74 12 Kenkmann A, Price GM, Bolton J and Hooper L (2010). Health, wellbeing and nutritional status of older people living in UK care homes: An exploratory evaluation of changes in food and drink provision. BMC Geriatr. 10:28

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FOOD & DRINK

PLANT STEROLS AND STANOLS: AN OVERVIEW Junee Sangani Senior Specialist Diabetes Dietitian Junee is currently a Specialist Diabetes Dietitian at Central Middlesex Hospital, London North West Healthcare NHS Trust. She also works as a Freelance Dietitian. Her specialist areas of interest are chronic diseases, adolescent care and women's health.

From as far back as the 1950s, it has been known that increasing dietary intake of plant sterols and stanols can lower serum total and LDL cholesterol.1 Plant sterols and stanols provide an important role in building plant membranes. They naturally occur in all foods of plant origin such as fruits, vegetables, grain products, seeds and nuts and are especially high in vegetable oils. The dietary intake of naturally occurring plant sterols and stanols is thought to be approximately 200400mg/d and in vegetarian diets it can be double the amount.2 Functional food products enriched with plant sterols and stanols have been marketed since 1995, with margarines being the pioneers. Today, there is a large variety of products including drinks, yoghurts and supplements.1,3 PLANT STEROL AND STANOL FUNCTION

Sterols and stanols have a similar function in plants as cholesterol has in humans; they chemically resemble the structure of cholesterol. There are very slight differences in the structure of sterols, stanols and cholesterol which make them profoundly different in metabolic function. They work by competing with and inhibiting cholesterol absorption in the small intestine, leading to excretion of cholesterol. It is also thought that they regulate hepatic expression of LDL receptors and decrease production of LDL cholesterol. Commonly found plant sterol and stanols are campesterol, campestanol, sitosterol and sitostanol.1,4,5 Plant sterols and stanols have the same mechanism for cholesterol lowering as Ezetimibe, a drug that lowers plasma cholesterol levels, so taking them together doesnâ&#x20AC;&#x2122;t provide any additional benefit and they both appear to reduce cholesterol levels equally.1

Statins work in a different way by inhibiting HMG-CoA reductase, which is an enzyme that plays an important role in cholesterol production, leading to reduced cholesterol synthesis. The cholesterol lowering effect of statins has been proven to reduce the incidence of heart attack and stroke; however, no such effect has been documented with plant sterol and stanol enriched foods and supplements.1,3 However, combining plant sterols and stanols with 2g/d of statins has been shown in clinical trials to reduce LDL cholesterol by 7-10% above the reduction effect of the statin. It is thought that a similar or better than effect is achieved by doubling the statin dose.6,7 RECOMMENDATIONS

It has been well documented that an intake of 2g per day of plant sterol and stanols can lower LDL cholesterol by 8-10%.1 Certain products claim that an intake of 1.5-2.4g per day can lower cholesterol by 7-10% and an intake of 2.5-3g per day can lower by 10-12.5% in two to three weeks.8 It is recommended that these products are eaten with meals to be effective and, if intake of the product is stopped, the cholesterol lowering effect will also stop.5 Overleaf is a guideline to show what is needed to be consumed to get 1.5-3g plant sterol and stanol per day and a table of some of the products available. www.NHDmag.com July 2017 - Issue 126

FOOD & DRINK

Plant sterols and stanols provide an important role in building plant membranes. They naturally occur in all foods of plant origin such as fruits, vegetables, grain products, seeds and nuts . . .

Either: a) one plant sterol or stanol fortified mini yoghurt drink per day, or b) two to three portions of any of the foods below, providing at least 0.8g of plant sterol per day: • two teaspoons fortified spread (10g) • one fortified yoghurt • a glass (250ml) milk There is considerable variation between an individual’s response to stanols and sterols and this tends to be dose-related. An individual’s LDL response can also vary depending on their baseline LDL cholesterol levels and possibly the type of product chosen and the frequency of intake. Plant sterols and stanols taken in the form of a tablet appear to have a similar effect as that taken in other dietary forms.9 Plant sterols and stanols may be more effective when taken as multiple doses, and the type of plant sterol or stanol enriched food product may affect the results. Further research is needed.10,11 It is not clear what the optimum intake of plant sterols and stanols is and there are limited studies to show the effects of high dose 30

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plant sterols and stanols in humans. However, it appears that eating more than 3g per day of plant sterols and stanols seems to have very little additional effect on cholesterol lowering and may have the adverse effect of reducing the absorption fat soluble vitamins and carotenoids. Reduction may be undesirable and lower concentrations have been associated with an increased risk of several chronic diseases, such as cardiovascular disease (CVD), cancer and age-related macular degeneration (AMD), although evidence from randomised controlled trials is lacking.12 Plant sterols and stanols are not recommended for pregnant or lactating women, or for children aged under the age of five. In pregnant women, they have been shown to reduce the level of carotenoids, including vitamin A which is closely associated with foetal development. In addition, generally, cholesterol is required in the developing brain.13 Plant sterols and stanols have been shown to reduce LDL and total cholesterol. High cholesterol levels have been shown to increase the risk of coronary heart disease and stroke. However, there is limited data and no randomised controlled trials which examine the effect of plant sterols and stanols on cardiovascular outcomes.

Table 1: Examples of products available in the UK Plant sterol/ stanol product

Cost

From £.7.80-£10

Dose Vitabiotics Ultra Plant Sterols 30 tablets per box 1500mg (3 tablets/d) Recommended dose 2-3 tablets (1000-1500mg/ 1-1.5g/d)

£3.60

Flora ProActiv Light Cholesterol Lowering Spread 500g per tub Recommended dose and 3 x servings/d Each serving is 10g

£3.65

Benecol Light Spread 500g per tub Recommended dose and 3 x servings/d Each serving is 10g containing 0.8g plant sterol

£1.50

Asda Cholesterol Lowering Spread 500g per tub Recommended dose and 3 x servings/d Each serving is 10g containing 0.75g plant sterol

£2.55

Benecol Fat Free Berries Yoghurts x 4 pots 125g per pot Each pot contains 0.8g Recommended dose and 3 x servings/d

£3.25

Benecol Yoghurt Drink Blueberry x 6 bottles 65.5g per bottle 2g plant stanol per bottle Recommended dose 1x per day

£2.25

£1.40

Tesco Cholesterol Reducing Blueberry Yoghurt Drink x 6 bottles 100g per bottle 2g plant stanol per bottle Recommended dose 1x per day

Flora ProActiv skimmed milk 1 litre carton Each 250ml serving contains 0.75g Recommended dose 3 x per day

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FOOD & DRINK For this reason, the recent NICE guideline update states that patients should not routinely be advised to take plant sterols and stanols until there is sufficient evidence to show this.14 FUTURE RESEARCH AREAS

There may be a place for plant sterols and stanols to treat hypercholesterolemic children who are still not candidates for statin therapy, or who receive only low-dose statins, and also for people who donâ&#x20AC;&#x2122;t tolerate statins very well. However, there is not enough information on the efficacy of plant sterols and stanols to be used as a sole therapy in this way.3 In animal studies, plant sterols and stanols have been shown to improve fatty liver through the mechanism of intestinal cholesterol absorption, further trials are needed in humans, but, it is thought that they could play a role in reducing liver fat and inflammation in nonalcoholic fatty liver disease.16 There is some concern that elevated serum plant sterols and stanols may be atherogenic. Phytosterolemia (Sitosterolemia) is a rare disease with elevated serum plant sterol and stanol concentrations due to genetic mutation which can be 50-200 fold compared to the normal

population. These patients commonly have hypercholesterolemia. However, as this disease is so rare, currently little is understood and there is a lack of knowledge about the mechanisms of this condition; a small study showed that of five subjects with Phytosterolemia, despite having elevated plant sterol and stanol levels, none had clinical symptoms of CVD or markers of atherosclerosis.1 CONCLUSION

Overall, plant sterols and stanols have gone through rigorous testing and there is a large body of evidence to back their safe long-term use. It is not essential to take plant stanols or sterols to help manage blood cholesterol levels. Some individuals may choose to take sterols and stanols to reduce their cholesterol levels especially if they have familial hypercholesterolemia or are following the portfolio diet which is a recognised approach to lowering cholesterol16 We must keep in mind that although sterols and stanols have been shown to successfully decrease LDL and total cholesterol, there is limited research about the cardiovascular outcomes and further research is required in this area.

References 1 Helena Gylling and Piia Simonen (2016). Are plant sterols and plant stanols a viable future treatment for dyslipidemia? Expert Review of Cardiovascular Therapy, 14(5): 549-551 2 Ras RT, Geleijnse JM, Trautwein EA (2014). LDL-Cholesterol- lowering effect of plant sterols and stanols across different dose ranges: a meta-analysis of randomised controlled studies. British Journal of Nutrition: 112, 214-219 3 CofĂĄn M and Ros E (2015). Clinical Application of Plant Sterol and Stanol Products. Journal of AOAC International: 98, 3 701-706 4 Han S, Jiao J, Xu J, Zimmermann D, Actis-Goretta L, Guan L, Zha Y, Qin L (2016). Effects of Plant Stanol or Sterol enriched diets on Lipid Profiles in patients treated with statins: Systematic Review and Meta-analysis. www.nature.com/ scientific reports 6, 31337 1-9 5 BDA food fact sheet (2015). Stanols and Sterols. www.bda.uk.comfood facts last cited 20/05/2017 6 Eussen SR, Rompelberg CJ, Klungel OH and van Eijkeren JC (2011). Modelling approach to simulate reductions in LDL cholesterol levels after combined intake of statins and phytosterols/-stanols in humans. Lipids. Health. Dis 10, 187 7 Gylling HPJ, Turley S et al (2014). Plant sterols and plant stanols in the management of dislipidaemia and prevention of cardiovascular disease Atherosclerosis. 232:346-60 8 Commission Regulation (EU) (2014) No 686/2014 of 20 June 2014 amending Regulations (EC) No 983/2009 and (EU) No 384/2010 as regards the conditions of use of certain health claims related to the lowering effect of plant sterols and plant stanols on blood LDL-cholesterol. Journal of the European Union [online] Available at http://eur-lex.europa.eu/legal-content/EN/TXT/?qid=1424856119984&uri=CELEX:32014R0686 [Accessed 20 May 2017] 9 Amir Shaghaghi M, Abumweis SS, Jones PJ (2013). Cholesterol-lowering efficacy of plant sterols/stanols provided in capsule and tablet formats: results of a systematic review and meta-analysis. J Acad Nutr Diet. Nov; 113(11): 1494-503 10 AbuMweis SS, Vanstone CA, Lichtenstein AH et al; Plant sterol consumption frequency affects plasma lipid levels and cholesterol. Eur J Clin Nutr. 2009 Jun 63(6): 747-55. Epub 2008 Jun 4 11 AbuMweis SS, Barake R, Jones PJH (2008). Plant sterols/stanols as cholesterol lowering agents: A meta-analysis of randomised controlled trials. Food and Nutrition Research DOI IO.3402/fnr. v52iO.1811 12 Baumgartmer S, Ras TR, Trautwein EA, Mensinki RP, Plat J (2017). Plasma fat soluble vitamin and carotenoid concentrations after plant sterol and plant stanol consumption: a meta analysis of randomised controlled trials, Eur J Nutr 56, 909-923 13 Laitinen K, Isolauri E, Kaipiainen L, Gylling H, Miettinen TA (2009). Plant stanol ester spreads as components of a balanced diet for pregnant and breastfeeding women: evaluation of clinical safety. Br J Nutr, 101(12): 1797-804 14 NICE (2014) updated 2016. Cardiovascular disease: risk assessment and reduction, including lipid modification 15 Plat J Hendrikx T, Bieghs V et al. (2014) Protective role of plant sterol and stanol esters in liver inflammation: insights from mice and humans. Plos ONE. 9, 10 16 https://heartuk.org.uk/cholesterol-and-diet/six-super-foods-for-lower-cholesterol/portfolio-diet (last cited on 23/05/2017)

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CONDITIONS & DISORDERS

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

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

CYSTIC FIBROSIS: NUTRITIONAL STRATEGIES AND MANAGEMENT It is well documented that optimal growth and nutrition in children with cystic fibrosis (CF) is crucial to maintain health and lung function.1-3 Lung disease and nutritional status are closely related4 and so, both are strong predictors of morbidity and mortality.5-7 It is essential that this patient group is assessed and monitored on a routine basis to help identify the most appropriate nutritional strategies and assess their outcomes. Debate has ensued, however, as to the best measures to use in order to assess growth in patients with CF, in view of recently published guidelines. There is then the struggle to maintain the optimal nutritional status and how best to achieve this. ASSESSMENT OF GROWTH

In CF, nutrition is considered to be adequate when growth is similar to that of an age-matched healthy population.8 It is, therefore, paramount that growth in children with CF is closely monitored. Appropriate growth charts should be used, according to the nationality and ethnicity of the child. In the absence of those, the World Health Organisation (WHO) growth charts should be used. In a busy clinical setting, Body Mass Index (BMI), being quick and simple to calculate, is accepted as being the most appropriate measure of nutritional status in children with CF over the age of two years. (BMI cannot be used in children under the age of two years, as there are no reference values for BMI percentiles (BMIp) for this age group.9-11)

BMI determines whether weight is in the appropriate range for height. In children, BMIp has been reported to be a more sensitive marker of nutritional failure than other weight and height based measures such as percentage ideal body weight.12 In children over the age of two years, a BMIp of less than or equal to the 20th percentile is associated with a reduced lung function and low bone mineral density, compared to a BMIp greater or equal to the 50th percentile which is associated with better lung function.1,9 The US Cystic Fibrosis Foundation (CFF) and the European CF Society both emphasise the use of BMI percentile for older children and adolescents, aged two to 20 years, with a BMI target at or above the 50th percentile for healthy children.8,9 The CFF Consensus Report criteria defines nutrition-related compromise as BMI <C10th, nutritional risk BMI C10th25th and acceptable nutritional status BMI >C25th.13 However, as BMI adjusts for height, this can mask nutritional stunting and so it must not be used in isolation in growing children. It is still important to review any change in height percentile/ SD score.14-16 Pubertal delay may also affect BMI, so requires consideration when www.NHDmag.com July 2017 - Issue 126

FROM HOLDING BACK.. . .TO HOLDING JACK

. .In a shot SOMETIMES PATIENTS CAN’T MEET THE ENERGY REQUIREMENTS THEY NEED THROUGH NORMAL DIET AND ONS ALONE.1

IT’s BEEN SHOWN TO:

Little wonder it helps so much

55% 92% 67%

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

Pro-Cal shot is a food for special medical purposes and should be used under strict medical supervision. ® Reg. Trademarks of Société des Produits Nestlé S.A.

Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool L3 4BQ, UK. Tel: 0151 709 9020 vitaflo.co.uk abbottnutrition.co.uk A Nestlé Health Science Company

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

All information correct at the time of print. December 2016

Table 1: Breakdown of nutritional therapy data from the UK Cystic Fibrosis Registry 2015, Annual Data Report, published August 2016 Overall (n=9587)

<16 years (n=3845)

≥16 years (n=5742)

Any supplemental feeding n(%)

3126 (32.6)

1120 (29.1)

2006 (34.9)

Nasogastric tube

109 (1.1)

15 (0.4)

94 (1.6)

Gastrostomy tube/ button

557 (5.8)

220 (5.7)

337 (5.9)

7 (0.1)

Jejunal TPN

assessing nutritional status and interpretation of growth charts. With delayed puberty, height percentile is initially lost but then catches up when the child enters their delayed growth spurt. This emphasis on the use of BMI has, however, come in for criticism. Konstan et al17 analysed data from the Epidemiologic Study of CF to compare patient weight for height (WFA), height for age (HFA) and BMIp for 11,769 children aged two to 18 years. The study found that a large number of children with CF who have a BMI at or above the 50th percentile have poor growth or nutritional status based on weight and/or height. In particular, children who were short for their age had relatively raised BMI values. Those with a BMI between the 25th and 50th percentile and who were not considered to be nutritionally ‘at risk’ according to the guidelines, were often found to have a poor nutritional status based on weight and/or height. More than one in six had WFA below the 10th percentile and one in four had HFA below the 10th percentile. This paper highlights that although achieving a BMI percentile of 50th is desirable, some children with CF who have a BMI at or above the 50th percentile can still demonstrate poor nutritional status when evaluated by weight and height for age. It also highlights the risk of only identifying nutritionally compromised children with a BMI below the 25th percentile and that solely relying on BMI will fail to identify a large number of children with CF who are short and underweight for their age. One criticism of this study is that the measures used were from between 2003 and 2005 and so this needs to be repeated using more recent values. However, it does highlight the need for guidelines to consider the importance of monitoring weight and height for age in addition to BMI.

A recently published and validated nutrition screening tool18 for children with CF, used BMI along with other anthropometric data. This included weight gain/loss/maintenance and height gain/maintenance. The height assessment was based on the last year and also took into consideration pubertal staging. In designing a tool based on progression of nutritional status, a risk was identified in patients who appeared to have acceptable nutritional status but whose weight and height were stationary or increasingly below acceptable levels. This screening tool identified 15 patients as being at nutritionally at risk, who had previously been identified as having ‘acceptable nutritional status’ by the CFF Consensus Report criteria. It, therefore, has higher sensitivity compared to the CFF Consensus Report criteria. Although this screening tool incorporates other clinical variables to help identify nutritional at risk patients, this higher sensitivity could in part be attributed to being based on progression of nutritional status, analysing weight and height gain over time, rather than solely being based on BMI. NUTRITIONAL STRATEGIES

It can be a struggle to achieve and/or maintain optimal nutritional status, even from early on in life for children with CF. Dietary counselling, oral nutritional supplements, maximising absorption, behavioural modification and enteral tube feeding (ETF) are all strategies that can be used to aid weight gain and growth in CF. Table 1 shows a breakdown of nutritional therapy data from the UK Cystic Fibrosis Registry 2015. There is, however, a lack of good quality studies to assess the effectiveness of some of these strategies. Vered et al19 reviewed the randomised control trials that addressed nutritional www.NHDmag.com July 2017 - Issue 126

CONDITIONS & DISORDERS

Once undernutrition has been identified, there are a number of nutritional strategies that can be employed to improve nutritional status interventions in patients with CF. They found 51 randomised control trials, but only a minority provided the full methodology; they had small patient numbers with no sample size calculations; the mean intervention period was short, only six months and more than half did not define a primary outcome. They also highlighted the lack of outcomes that are important to the patient. ENTERAL TUBE FEEDING

For some children with CF, ETF can be useful in achieving the desired optimal nutritional status. Current UK and European guidance, however, does not include detailed recommendations for ETF. Although there are small single centre multiple retrospective studies demonstrating that ETF can improve age dependent measures of growth, such as weight/age percentile, length/ age percentile, weight for height percentile and BMI and suggestion of improved lung function, there are no randomised clinical trials. A recent systematic review23 has assessed the literature published after 1997, describing the effectiveness of nutritional interventions in patients with CF. Seventeen research articles were reviewed, focusing on behavioural interventions (n=6), oral supplementation (n=4) and ETF (n=7). The latter intervention was universally successful at promoting weight gain. One behavioural study and two oral supplementation studies also reported significant weight gain. The review concluded that ETF is effective in improving nutritional status, while the effects of behavioural intervention and oral supplementation are not sufficiently consistent at present. Additionally, ETF is especially effective at improving the nutritional status in malnourished patients and slowing down further pulmonary function decline. In 2016, the CFF published evidence informed guidelines24 based on a systematic review of the evidence and expert opinion. 36

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Thirty-three Consensus statements have been recommended. Areas addressed include when to consider ETF, assessment of other influences resulting in poor nutrition, counselling the child and family for placement of ETF, post insertion management of the tube and education on ETF. One area that should be highlighted is the recommendation that the child and family are educated about nutrition, including the role of ETF, throughout their lifetime. Although nutrition is highlighted from the point of diagnosis, all too often ETF discussions take place when all other nutritional options have failed and so families often view it as an option borne out of failure rather than as an alternative, successful option. The CFF highlight the benefits of early introduction of ETF to allow the child and family to be happy with their choice and be inclusive in the decision making. CONCLUSION

Despite all the evidence that optimal growth and nutrition in children with CF is crucial to maintain health and lung function, the best measures to use in order to assess growth in patients with CF have still to be agreed. Whilst BMIp has been reported to be a more sensitive marker of nutritional failure than other weight and height based measures, it does not take into consideration children who are short for their age and have relatively raised BMI values. Solely relying on BMI may fail to identify a large number of children with CF who are short and underweight for their age. Once undernutrition has been identified, there are a number of nutritional strategies that can be employed to improve nutritional status, including ETF. Although there has recently been published evidence informed ETF guidelines, further areas of research are still required in this area.

SKILLS & LEARNING

THE DIETETIC VIRTUAL CLINIC: IMPLEMENTING A HOSPITAL SERVICE Alice Lunt, RD Cardiorespiratory Dietitian, Royal Brompton Hospital, London

Alice is an active member of the British Dietetic Association and Treasurer for the BDA’s Critical Care Specialist Group. She is also Health Advisor for the British Lung Foundation.

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

Since March 2017, there has been a Royal Brompton virtual dietetic service and this article takes a look at how it has been implemented and the ongoing improvements being made to the service. The Royal Brompton Hospital, London is part of a cardiorespiratory tertiary trust and, therefore, patients can be local, national or international. The geographical implications mean it is often impractical for patients to be seen by a dietitian outside of their hospital admission. We have not been able to provide a dietetic outpatient service to adult cardiac or respiratory patients. From the clinicians’ perspective outpatient clinics have not been possible due to limited room availability, especially if we were to link with other appointments. In March this year, we introduced a virtual dietetic service based on ‘Telehealth’, a digital way to interact with patients within the hospital dietetic service. Telehealth uses technology, such as telephone, email, Skype or websites to support clinical healthcare, including health promotion, disease prevention, diagnosis or therapy.1 The term

‘telehealth’ is gaining momentum, but published evidence is limited in the field of dietetics and in the UK. Nevertheless, positive patient experience and compliance have been reported in rural Canada and Australia.1,2 A Cochrane review of 21 chronic disease studies and telehealth reported positive results for quality of life, efficiency, acceptability and cost effectiveness, together with improved clinical results in heart failure and diabetes.3 It was reported in 2014 that 76% of the GB population use internet on a daily basis4 and with telehealth no longer a new concept, NHS England is becoming more aware of its potential use; an example being a Clinical Commissioning Group (CCG) commissioning for quality and innovations (CQUIN) 2016/17 target is based around telehealth to support patients and colleagues, with financial rewards if achieved.

Figure 1: Results from a cross-sectional service evaluation at the Royal Brompton Hospital into the use of telehealth Would like dietetic input after leaving the ward:

skype 4%

phone 63%

email 33%

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SKILLS & LEARNING

Telehealth uses technology, such as telephone, email, Skype or websites to support clinical healthcare, including health promotion, disease prevention, diagnosis or therapy. ACCEPTABILITY ASSESSMENT

In early 2016, a cross-sectional service evaluation was carried out in the Royal Brompton hospital to consider the potential use of telehealth by the target audience (43% aged over 65 years old and 87% aged over 45 years old). It was reassuring to find that 64% would want ongoing dietetic input following discharge and the majority (62%) would prefer a form of telehealth for ongoing communication (see Figure 1). On further questioning, there was found to be a preference for phone (63%) rather than email (33%) or skype (4%). From the practical side, 83% reported having access to scales at home. Summary of key stages of implementation process: 1. Clinic set up on Lorenzo booking program 2. Development of supporting admin materials 3. Clinic trial then launch with ongoing reflection and improvements 4. Promotion 5. Outcomes data analysis CONSIDERATIONS AT EACH STAGE IN THE PROCESS

1. Clinic set up on booking program Gaining support from the hospital information technology team and outpatient manager was essential to enable this aspect to be possible, as this is not an area or even a computer program that adult dietetics have previous experience of. We considered the following: • allocation of name of clinic and lead consultant; 38

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• time allocation and clinic template; • allowing time for admin; • suitable room to ensure confidentiality, minimal background noise, as well as phone signal and internet access, but not as formal as a clinic room; • laptop with suitable programs and access; • telephone consultation; • smart card, computer program access and training. 2. Development of supporting admin materials For the clinic to run, supporting resources needed to be developed. Local and national resources were found by an intranet search and used as a point of reference for developing tailormade resources including: • referral criteria relevant and appropriate for adult dietetics; • referral forms which are quick, concise and provide useful information to enable prioritisation; • clinic appointment letter for new and follow-up appointments; • outcome letters for new, follow-up and DNA (did not arrive) appointments following clinics, uploaded, as well as send to referrer, patient and GP (Electronic notes); • generic email with multiple access; • feedback form; • excel spreadsheet for monitoring referrals and booking; • printable information and sample delivery services to support dietary advice provided.

Figure 2: Patient referrals - reason for referral

3. Clinic trial run, then full launch a fortnight later Since introducing the virtual dietetic service at The Royal Brompton back in March this year, ongoing reflection on ways in which to improve the service has been important. The following changes have already been implemented to overcome barriers identified: • We have sought a dial code to enable calling mobile phones without going through switchboard which was causing delays. • We have started to keep a record of phone numbers with the clinic bookings to optimise efficiency. • Initially appointment booking letters needed to be written manually, whereas now the computer system can produce these automatically following appointment booking. • We have adjusted the laptop settings to stop it logging out or locking the screen during the consultation. This enables documentation directly on to electronic records rather than using paper. • Our referral process is being reviewed to use an electronic program as used for bloods requests, rather than the current electronic form which is then emailed. • Skype has proved difficult due to information governance; the trust has Skype for business; however, this is challenging to use, even for interviews. • We now seek patient consent to email letters, as currently posting takes additional time and resources.

4. Promotion The ongoing feasibility of the clinic is dependent on referrals and, therefore, the following promotions have taken place to raise awareness of telehealth dietetic clinics: • Announcement to multidisciplinary team via email and during meetings. • Involvement of key stakeholders throughout the process including physiotherapists, consultants, dietitians. • Electronic referral and criteria link on intranet via simple search. • Ongoing informal verbal reminders and via patient letters. • Informed CQUIN team to support the NHS England funding bid. • Linked with hospital marketing and communications resulting in promotion article publication in monthly bulletin which is emailed to all and printed versions distributed around the hospital. 5. Outcomes data analysis It is still very early days following the initiation of the clinics and, therefore, this has not been formally assessed or monitored, but this is crucial going forward to ensure sustainability and feasibility. General observations so far: • There have not been any DNAs. • Works for dietitian, MDT and patients, with positive feedback to support this. • Outcomes data being collected includes source of referral, reason for referral, weight changes, BMI changes and transplant www.NHDmag.com July 2017 - Issue 126

SKILLS & LEARNING Table 1: Feedback from colleagues and patients Patient feedback

Healthcare colleague feedback

Extremely likely/likely they would recommend this service to friends and family.

“That’s brilliant. It is great that you are planning on offering weight loss management advice as well. This will also certainly help to close the loop for the COPD cohort."

There was adequate time. “I look forward to our next telephone call.” The clinic is Excellent/Good.

The call was clear and they were able to understand what was being discussed.

The letter prior to appointment provided adequate and clear information.

The session was useful.

listings (as some referrals are needing to reduce weight to be listed for transplant), hospital admissions or lung function. Figure 2 shows a breakdown of patient referrals. FEEDBACK

Feedback from colleagues and forms posted to patients following initial assessment of the virtual service has provided reassuring, useful and consistently positive feedback (see Table 1). SUSTAINABLE FUTURE

Going forward, there will be ongoing reflection, changes, promotion and efforts to optimise cost-effectiveness including: ongoing promotion; • outcomes data to show effectiveness and sustainability; • optimisation of efficiency and cost effectiveness; • local guideline to support training of dietetic colleagues;

“This is fantastic news! From an outpatient perspective, we desperately need a weight loss service. This could go hand in hand with other ideas we are developing.”

“Everyone I have mentioned this service to have said that it is a brilliant idea and have been very happy to be referred. I think the fact that we are a tertiary centre means that the idea for a virtual clinic is a brilliant way to support our patients and I hope this is something that will only grow in the future.”

"From a clinician point of view, I think the forms are very quick and easy to fill out."

• support of other disciplines internally or external, with setting up virtual clinics if needed. A similar service has already been initiated in other areas of the trust following our implementation of the virtual clinic; • extending to offer Skype when local information governance guidelines allow; • conference abstract submission. It has been rewarding to follow on from patients and colleagues requesting a virtual dietetic service to actually implementing the service this year. To date, the referrals continue to arrive, together with positive response to the new service, making it likely to continue. With supportive colleagues and some new resources virtual clinics can be a useful resource for adult dietetics to utilise. It may not be suitable, or its use in isolation may not be appropriate for all specialities in dietetics; however, this positive experience for all involved shows it has a place.

Any questions or for further information do get in contact. Email: dietitianclinic@rbht.nhs.uk 40

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PAEDIATRIC

AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER Priya Tew Freelance Dietitian Priya runs Dietitian UK, a freelance dietetic service that specialises in eating disorder support. She works with NHS services, The Priory Hospital group and private clinics. Priya also provides Skype support to clients nationwide.

Avoidant/restrictive food intake disorder (ARFID) is a fairly new type of eating disorder, but one which is now the second most common eating disorder in children 12 years and younger. It is sometimes called picky eating and was formally categorised in 2013. The definition for ARFID in The Diagnostic and Statistical Manual of Mental Disorders (DSMâ&#x20AC;&#x201C;5) includes an eating or feeding disturbance (e.g. a lack of interest in eating/food, avoidance of foods due to sensory concerns and/ or aversion to foods), with a persistent failure to meet appropriate nutritional or energy needs.1 One or more of the following should be associated with ARFID: weight loss (or failure to gain weight in children), significant nutritional deficiency, the need for enteral feeding or ONS and an effect on psychosocial functioning (see Table 1). The issues should not be due to an unavailability of food, food poverty or any cultural eating practices and it should not be better described by any other medical condition.

SIGNS AND SYMPTOMS

There may be no outward obvious signs that someone is suffering from ARFID. Most sufferers want to make changes to their eating habits but do not know how to move forward with it. More obvious physical symptoms include retching and vomiting around foods, anxiety with eating, loss of appetite, abdominal pain and socially avoiding being around food. There are usually safe and excluded foods. These foods may be categorised by certain brands, food groups, smells, colours and textures. Some people may only like to eat very hot/cold foods, may have to eat foods without any sauces, or eat foods presented in a certain way. There is fear around eating certain foods that can be overwhelming

Table 1: DSM-5 diagnosis of avoidant/restrictive food intake disorder1,2 A An eating or feeding disturbance (e.g. apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 1. Significant weight loss (or failure to achieve expected weight gain, or faltering growth in children). 2. Significant nutritional deficiency. 3. Dependence on enteral feeding or oral nutritional supplements. 4. Marked interference with psychosocial functioning. B The disturbance is not better explained by lack of available food or by associated culturally sanctioned practice. C The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one's body weight or shape is experienced. D The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. www.NHDmag.com July 2017 - Issue 126

PAEDIATRIC

Children

are taught relaxation

techniques with an aim to reduce the anxiety around

foods. One technique is to and disturbing to watch. Often this can be perceived as the patient being difficult or acting out behaviourally, but there is usually an underlying reason for the fear. Unlike anorexia and bulimia, there are no fears around weight gain, less comorbidity and fewer eating disorder behaviours, such as hiding food and manipulating their weight. However, the same anxiety around food is present. The research suggests that ARFID is more likely to affect males and is more likely to present before the age of 12.3 Some of these patients can then be at risk of anorexia nervosa, so highlighting these groups could be a way to prevent the eating disorder progressing. A study by Fisher et al found the main reasons for ARFID were picky eating from childhood, anxiety, fear of vomiting or choking, food allergies and gastrointestinal symptoms.1 People with ARFID are also more likely to have another medical condition alongside. A review of adolescents with eating disorders compared those with Anorexia nervosa, bulimia and ARFID.3 Adolescents with ARFID had a lower bone mineral density (BMD), especially in their 42

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create a storyline around the foods.

lumbar spine, but they have similar rates of depression. Triggers for the development of the selective eating were bullying, weightbased teasing and trauma around food, such a choking or vomiting after eating something. Having ARFID will have an impact on a person socially, making it harder, or not possible, to eat out; eating at work or school can be difficult and may lead to them missing lessons due to the time it takes to complete a meal.5 Subcategories of ARFID include the following: 1. Sensory-based avoidance, where the person refuses foods based on smell, tastes, texture, colour and presentation. 2. Lack of interest in food and not being able to tolerate being near it. 3. Negative experiences with the food, leading to anxiety and fear around it.

RISK OF OTHER CONDITIONS

Eighty percent of children with a developmental disability also have ARFID. Children with ARFID often show signs of obsessive compulsive disorder or autism, but may not meet a full clinical diagnosis. For example, they may struggle with making change and will like strict routine. A study by Schreck et al6 found that children with some degree of autism spectrum disorder (ASD) had significantly more issues with food, being more selective in their food choices and eating a narrower range of foods. TREATMENT

Over time, the symptoms of ARFID should lessen and to some extent children can grow out of it. There may not be a need to treat a low severity case. When the fears around certain foods become overwhelming and lead to the patient not being able to properly nourish themselves, then intervention is needed. Obviously nutritional deficiencies will need correcting and may impact on a child’s growth, but also ARFID may develop into a more severe eating disorder such as anorexia nervosa. Early treatment can help prevent this. For some cases, treatment will involve outpatients’ appointments, dietetic support and therapy and oral nutritional supplementation and, for some, it can require hospitalisation. Although the calories required for weight restoration are the same in anorexia nervosa and ARFID patients, more patients with ARFID are enterally fed and longer hospitalisations tend to be needed.4 Support is helpful if the child is nutritionally deficient, if weight is a concern, or symptoms become a problem socially, or if the symptoms continue into adulthood. Cognitive behavioural therapy is the main form of treatment. This focuses less on

the food and more on changing behaviours. Talking about why food is needed and what the different food groups provide is a good educational point and can give the person motivational reasons to eat. Replacing the scripts of fear with positive scripts can reduce the anxiety. Other anxiety management techniques including breathing, journaling and relaxation can also enable people to start to increase the range of foods that they eat. Simple mealtime management techniques, such as distraction with conversation, having a calm environment, putting a candle on the table to focus on, may all be helpful. Specifically for children, there is a fourstage treatment programme that is used, based on systematic desensitisation. Stage 1: Record. Children keep a log of eating behaviours and their feelings. Stage 2: Rewards. Children write a list of foods they would like to try. This can be variations on current foods, prepared in a different way, or a different brand. Rewards are given when they try something new. Stage 3: Relaxation. Children are taught relaxation techniques with an aim to reduce the anxiety around foods. One technique is to create a storyline around the foods, using their favourite people and/or places so that they can imagine themselves enjoying the foods as a prelude to eating them. Stage 4: Review. It is key to also keep track of how a child is progressing and feed this back to the family and child, as it can sometimes be hard to see how much change has been made.

ARFID is a fairly new diagnosis and is an eating disorder subcategory. More research is needed to look at optimal approaches to refeeding and why the disease is triggered. However, a lot of the treatments used in anorexia nervosa will be able to be adapted and transferred through for this patient group.

References 1 Fisher MM et al (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: A ‘new disorder’ in DSM-5. J Adolesc Health; Vol 55 (1): 49-52 2 Diagnostic and Statistical Manual of Mental Disorders (DSM-5). www.psychiatry.org/psychiatrists/practice/dsm 3 Norris ML et al (2014). Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. Int J Eat Disord; 45 (5): 495-9 4 Strandjord SE et al (2015). Avoidant/restrictive food intake disorder: illness and hospital course in patients hospitalised for nutritional insufficiency. J Adolesc Health; 57 (6): 673-8 5 What is ARFID? The Centre for Eating Disorders Blog. http://eatingdisorder.org/blog/2013/08/what-is-arfid/ 6 Schreck KA, Williams K, Smith AF (2004). A comparison of eating behaviours between children with and without autism. J Autism Dev Disord. 2004. Aug; 34 (4): 433-8

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PROF BLOG

VITAMIN D - NO LONGER JUST THE SUNSHINE VITAMIN Simon Langley-Evans Professor of Human Nutrition, University of Nottingham

Simon has 25 yearsâ&#x20AC;&#x2122; experience in nutrition research, with expertise in maternal and infant nutrition. He is Chair in Human Nutrition and Head of School of Biosciences at the University of Nottingham and is the Editor-inChief of The Journal of Human Nutrition and Dietetics.

In the last decade, understanding of the role of vitamin D in not just bone health, but in many other aspects of physiology, metabolic regulation and health, has exploded and vitamin D is very much a hot topic in nutrition research. Vitamin D has long been recognised as one of the essential nutrients and the contribution of vitamin D deficiency to rickets in children was determined early in the 20th century. Indeed, in the history of public health nutrition, measures to prevent rickets through administration of cod liver oil to children and improving access to milk were early success stories. Since then, the role of vitamin D in maintaining calcium homeostasis and hence bone health has been a major focus of interest. Vitamin D is most unlike the other vitamins in that it is largely derived from non-dietary sources. The action of UVB rays from sunlight upon 7-dehydrocholesterol in the skin leads to the formation of pre-vitamin D which is then metabolised to vitamin D. Vitamin D formed in the skin is metabolised to 25-hydroxy vitamin D in the liver. This undergoes a further hydroxylation step to form the active form of vitamin D; calcitriol. It is also more appropriate to think of vitamin D as a pro-hormone rather than a vitamin, as it has many of the properties of steroid hormones and like those hormones is ultimately synthesised from cholesterol. The process of synthesis of vitamin D is little impacted by dietary factors, although it is becoming clear that in individuals taking statins to lower cholesterol, vitamin D status may be compromised.

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Determining vitamin D status in human subjects has been a major research challenge for many decades. The best biochemical marker is 25-hydroxy vitamin D, but as described by New and Wilson,1 there has long been a challenge with standardising biochemical measurements so that comparisons can be made between laboratories and robust assessment of vitamin D insufficiency and deficiency (25-hydroxy vitamin D below 25nmol/l) can be made. For a long time, the value of measuring dietary vitamin D intake was considered to be questionable given the major contribution of synthesis within the body to overall vitamin status. However, with high levels of populationwide insufficiency of vitamin D, there is increasing use of fortification of foods and clear recommendations for certain sub-populations to consume vitamin D-rich foods. As a result, robust methodology is required to assess intake in research studies and dietary surveys. Weir and colleagues,2 for example, have validated a food frequency questionnaire for the estimation of vitamin D intakes in adults aged 18-64 years. Other researchers have used detailed dietary records to assess vitamin D in the diets of preschool children in the UK3 and have estimated that whilst major sources were fat spreads, milk and fortified cereals, all children in a sample of 755 18- to 40-month-olds were consuming vitamin D at a level below

US and UK dietary recommendations. This disturbing finding suggested that fortification of cereals should be more widespread with a level of 2Îźg per 100g of cereal being necessary to provide most children with adequate intakes. Vitamin D deficiency is common all around the world and risk factors include living in northern latitudes, increasing age, low consumption of dairy produce, low socioeconomic status and overall metabolic health. With morbid obesity, for example, severe deficiency has been observed in more than a third of people.4 As noted above, the contribution of vitamin D to maintaining calcium homeostasis and bone mineralisation is well-understood. When circulating calcium is low, vitamin D contributes to release from bone, but when calcium is adequate in the diet, vitamin D promotes gastrointestinal uptake and bone remineralisation. However, most studies suggest that whilst calcium intake is important for increasing bone mineral, vitamin D has been reported to have more of an effect on reducing fractures due to prevention of falls in elderly people with osteoporosis. This has been proposed to stem from beneficial effects of vitamin D on muscle strength and neuromuscular tone. A recent systematic review on the effects of vitamin D upon muscle strength in elderly people5 contradicts this view however, suggesting that vitamin D improves mobility with no clear impact on measures of muscle strength such as hand-grip.

Our understanding of the hormonal actions of vitamin D is increasing rapidly. With this new understanding comes the realisation that this vitamin can impact upon many aspects of human physiology at all stages of the lifespan. For example, Samimi and colleagues found that treatment of pregnant women who were at high risk of pre-eclampsia with a vitamin D and calcium supplement between weeks 20 and 32 of gestation, improved several measures of cardiovascular function, glycaemia and antioxidant status.6 Vitamin D is increasingly being linked to cancer and other non-communicable diseases in adulthood. As we make improvements in the direct measurement and non-invasive estimates of vitamin D status, it is becoming clear that insufficiency of this key nutrient is widespread in all populations, but particular among those living in the northern latitudes where formation from ultraviolet exposure is low during the winter months. As a result, the achievement of robust dietary intakes is of importance among particular population sub-groups, including the elderly and pregnant women. For more information on the fascinating science of vitamin D it is worth noting that The Journal of Human Nutrition and Dietetics and Nutrition Bulletin released a joint virtual issue on the subject in 2016.7 There is so much more to learn about this fascinating nutrient and the days of vitamin D just being the sunshine vitamin that is good for our bones are well and truly over.

You can read more Prof Blogs from Simon Langley-Evans in the Student zone at www.NHDmag.com

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PAEDIATRIC A DAY IN THE LIFE OF . . .

A NEW DANONE NUTRICIA EARLY LIFE NUTRITION KEY ACCOUNT MANAGER Belinda Mortell Registered Dietitian, Danone Nutricia Early Life Nutrition

Having left the NHS earlier this year, Belinda explains the challenges she faces in her new role. After two years in the NHS working part time as an acute dietitian and two service improvement projects, I felt it was time to move on with my career. On my 40th birthday I spotted a job advert for Danone, for a role based around my home in North Wales. This is a rare opportunity and it was just the right time for me. I needed a new venture, so I decided to apply. After a very challenging recruitment process I started my new role in March this year. I am in the middle of my initial seven-week training programme known as the ITC as I write this Day in the Life column. Training is all based at head office in Chiswick Business Park. The level of support and training is amazing, although it is very intense and I am away from home frequently at the moment. The large community team of account managers currently focus on Cows’ Milk Protein Allergy (CMPA) and Functional Gastrointestinal Disorders (FGIDs) in infants. This week at ITC, we have to gain a solid grasp of the infant formula, toddler food and newly launched breastfeeding and pregnancy fortified snack bar ranges. The whole training focuses on promoting and protecting the message that breastfeeding is best for baby and mum and that we must do nothing which could influence healthcare professionals to think otherwise. Other presentations have been on the weaning and snack range including information on new products and innovations in the pipeline. Channel Strategy (Marketing) presented to us an update on the Weaning Guide and Baby Symptom Checker. Science and

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Innovation then took us through the core infant feeding ranges, highlighting composition and the evidence behind all the other ingredients in the products. We then had an exam which was very nerve racking, followed by a further session by the legal and regulatory team. The key principles are around compliance including European Food Safety Authority (EFSA) rules on macronutrient and micronutrient composition through to advertising legislation. For example you cannot have an advert which shows a kiwi fruit next to a weaning product that does not contain kiwi! After lunch it was a two hour session on ‘Insights’ which is a psychometric tool to help employees to understand themselves and make the most of relationships in the workplace. DIETITIAN WORKING IN A SOLUTIONS TEAM

As a dietitian working in a Solutions (Sales) team, I am surrounded by colleagues who are not healthcare professionals. This is a real challenge for me, but I realise that the HCPC standards and code of conduct have been very useful and a great guide for me during this period of transition from NHS to industry, particularly around being professional, working appropriately and drawing on my knowledge and skills. And even though I am now in a sales role, I will always be a dietitian first and foremost. BRITISH DIETETIC ASSOCIATION (BDA)

On the train home this week, I receive an email from the newer members of the local branch, the North Wales and

I am in the middle of my initial seven-week training programme known as the ITC as I write this Day in the Life column. Training is all based at head office in Chiswick Business Park. North West England branch. Hopefully, we will be able to organise a CPD event this year in our area. We still need new Committee members, as several of us left recently, including me. Having stepped down from the BDA Council, I have recently joined the Allergy and Paediatric Special Interest Group of the BDA. I am still linked in with the Freelance Group on Facebook, which is a brilliant place to network and find out about what's happening in my profession. I hope

to then link up with other dietitians working in industry to see how we can come together to share ideas. It seems that we are very separate from our colleagues in the NHS and I feel that it is time we came closer together to improve patient outcomes, be more effective and find innovation solutions to some of the challenges in the NHS. Follow the BDA branch on Facebook or Twitter @NWNWBDA @BrDieteticAssoc

NETWORK HEALTH DIGEST

www.NHDmag.com A wealth of useful dietetic resources for all dietitians and nutritionists Make the most of your NHD Community! www.NHDmag.com July 2017 - Issue 126

BOOK REVIEW

SUSTAINABLE DIETS: How ecological nutrition can transform consumption and the food system Review by 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.

AUTHORS: PAMELA MASON AND TIM LANG PUBLISHER: ROUTLEDGE, JANUARY 2017 ISBN: 978-0-415-74472-0 (PAPERBACK) PRICE: Paperback £28.94

This is a mighty beast of a book, dedicated to the elephant in the room of nutrition science. Meaning the big and grey and trumpeting elephant of environmental threat . . . Actually, a herd of elephants that can trample over any societal plans for improvements of human health and equality and well-being. Elephants with the tags greenhouse gas emissions, water shortage, acidification, eutrophication, species collapse, marine Armageddon, genetic diversity shrinkage and control systems concentration. All the things that we know for sure will affect food supply and distribution and, ultimately, all human diets. Dr Pamela Mason is a nutritionist with expertise in food policy and public health. Co-author Dr Tim Lang is professor at the Centre for Food Policy at the City University of London. Both authors are dedicated to widening the discussions of ‘what is a good diet?’ to matters beyond the nutrient content of the foods we eat. With predictions of a global population increase of three billion people in the next 30 years, everything that is currently challenging in terms of food production and distribution will get more so. Ultimately needed, although not directly discussed in this book, are population-control measures. But what are the possible policies to address concerns of environmental crisis affecting food supply in the future? Mason and Lang identify eight possible policy responses to dietary (un)sustainability. These range from

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denial, to technical-fix solutions, to information-and-duty on consumer choices, to focus on human health aspects of diet, to just cutting the peak environmental challengers of beef and dairy production. All of these measures are discussed in detail, and all-of-theabove are the correct responses. The book is jam-packed with facts and figures describing eco-stress. As a taster: ‘Globally, the blue water footprint of food wastage - the consumption of surface and groundwater resources - is about 250km3 which is the equivalent to the annual water discharge of the Volga river, or three times the volume of Lake Geneva.’ The critique by Emperor Joseph II to Mozart about his Marriage of Figaro opera, “too many notes”, seems relevant. But perhaps too many notes are needed to convince all of us to consider and act on all the evidence that business-as-usual is not an option. And some national governments have issued guidelines. Mason and Lang praise Sweden for support of less meat consumption and local and organic food choices, but note subsequent reprimand from the EU on this. They praise Brazil for advice to eat freshly prepared foods, together with others whenever possible, and avoid packaged or advertised products. They especially commend the ambitious and sustainably principled national dietary

Sustainable Diets . . . is a highly detailed book full of brick-solid data on the most important food subject of today (and tomorrow).

guidelines from the tiny, but very rich kingdom of Qatar! They welcome brave but failed attempts by the US 2015 Dietary Guidelines committee, to introduce sustainable considerations into public health advice: they claim the US meat lobby successfully thwarted these developments. They note that even the Chinese government set a remarkable public consumption target of a 50% meat reduction in June 2016, although this is very painfully counterbalanced by the statistic that China subsidised pig production by $22 billion in 2012 ($47 per pig!). My favourite chapter is the one on real food economics. Mason and Lang call for moves from value-for-money to values-for-money. They use several measures to support the view that food is cheap and is very unlikely to be getting cheaper. EU figures on consumer spending of foods shows lowest amounts in the UK at less than 10%, rising to about 20% in most Eastern European countries. Agricultural prices using the wonderfully named Grilli-Yang index, shows an annual 1% decline from 1900; today the index is 40 percentage points down from levels of 1977-9. The chapter then considers issues of externalised costs, and polluter-pays costs, and Mason and Lang call on national and agricultural economists to develop wider pricing mechanisms to support the sustainable diet. The book critiques the limited success of education and labelling in changing consumer intakes of meat and dairy, but the huge volumes of data fizzle out fast in the discussions of population-wide effects on nutrient intake and health from sustainable diets. If UK diets were modified with a 90% increase in beans and pulses and a 78% reduction in red meat (calculated by Scarborough et al, 2016 to achieve

Eatwell Guide targets), what, for example, are predicted increases in iron-deficiency anaemia in pre-menopausal women? What fortification and/or supplementation policies could be used to address these? There is a huge dietitian-shaped hole in discussions of dietary consequences from sustainable diet policies, and predictions that in the future dietitians will be much needed to add sense and detail to these considerations is not rocket-science. In fact, Mason and Lang observe that dietitians may have become professionally distracted by the excitement of the mapping of the genome and less focused less on the social and behavioural traditions of nutrition science. They caution that dietitians and other food professions cannot bury their heads in the sand over these themes: “Their influence as ‘actors’ for the sustainable diet transition is considerable.” For all the infinite detail of food production issues threatened by environmental destruction, the main conclusions in the book observe the most extreme pinch-points from the consumption of fish, and the consumption of meat (especially ruminants) and dairy. For the UK diet, this means less animal-sourced proteins and more plant-sourced proteins. To what degree the mix of future UK diets will contain more beans and nuts, or more insects, or more synthetic laboratory-produced ‘meats’ is unknown: but future dietitians will be the expert advisors. Sustainable Diets by Mason and Lang is a highly detailed book full of brick-solid data on the most important food subject of today (and tomorrow). It is a really essential reference for all dietitians who want to participate in discussions and debates on food choices for the future. www.NHDmag.com July 2017 - Issue 126

ONLINE RESOURCES

WEB WATCH Useful information, research and updates. Visit www.NHDmag.com for full listings. NICE UPDATES VITAMIN D: INCREASING SUPPLEMENT USE IN AT-RISK GROUPS - PUBLIC HEALTH GUIDELINE (PH56) Initially published Nov 2014. Updated May 2017. This guideline covers vitamin D supplement use. It aims to prevent vitamin D deficiency among at-risk groups including infants and children aged under four, pregnant and breastfeeding women, particularly teenagers and young women, people over 65, people who have low or no exposure to the sun and people with darker skin. This guideline includes recommendations on how to: • increase access to vitamin D supplements including those provided as part of the Healthy Start supplements scheme; • increase local availability of vitamin D supplements for at-risk groups; • ensure health professionals recommend vitamin D supplements; • raise awareness of the importance of vitamin D supplements among the local population. Updates were required following the publication of the SACN vitamin D and health report in 2016. Full details can be found at www.nice.org.uk/ guidance/ph56

OBESITY: WORKING WITH LOCAL COMMUNITIES - PUBLIC HEALTH GUIDELINE (PH42) Initially published Nov 2012. Updated June 2017. This guideline covers how local communities, with support from local organisations and networks, can help prevent people from becoming overweight or obese, or help them lose weight. It aims to support sustainable and community-wide action to achieve this. The guideline has been updated to include people with disabilities. Recommendations include: • developing a sustainable, community-wide approach to obesity; • strategic leadership and coordinating local action; • involving the community, local businesses and social enterprises; • local authorities and the NHS as exemplars of good practice; • planning and implementing systems for monitoring and evaluation; • scrutiny and accountability. For more information and the full guideline visit:www.nice.org.uk/guidance/ph42

EATING DISORDERS: RECOGNITION AND TREATMENT - NICE GUIDELINE (NG69) Published May 2017. This guideline covers assessment, treatment; monitoring and inpatient care for children, young people and adults with eating disorders. It aims to improve the care people receive by detailing the most effective treatments. This guideline includes recommendations on: • identifying eating disorders; • treating anorexia nervosa; • treating binge eating disorder; • treating bulimia nervosa; • physical and mental health comorbidities; • assessing, monitoring and managing physical health; • inpatient and day patient care. This guideline updates and replaces NICE guideline CG9, published in January 2004. Full details can be found at www.nice.org.uk/ guidance/ng69

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NHS CHOICES BEHIND THE HEADLINES - YOUR GUIDE TO THE SCIENCE THAT MAKES THE NEWS An excellent feature on the NHS Choices website, which is regularly updated to debunk health-related news. Headlines explained include those on diet, lifestyle and general health information. The headlines are unpicked by explaining the topic of discussion clearly, where the research or news story came from, what the research entailed and how reliable the news actually is. The pages also signpost readers to useful and correct information. Links to the pages can be followed via the NHS Choices Twitter and Facebook pages - @NHSChoices. Well worth saving as one of your favourites and share it with patients and colleagues - www.nhs.uk/ News/Pages/NewsIndex.aspx

DEPARTMENT OF HEALTH AVAILABILITY OF GLUTEN-FREE FOODS ON NHS PRESCRIPTION - CONSULTATION NOW CLOSED Published May 2017. This consultation was seeking views on proposals to make changes to the availability of gluten-free foods that are prescribed on the NHS. ‘Changes to the prescribing of GF foods could save NHS resources and reduce the primary care prescription drugs bill by up to £25.7 million per annum.’ The options considered: • Option 1: Make no changes to the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004. Under this option, GF foods would continue to be prescribed in primary care at NHS expense as now. • Option 2: To add all GF foods to Schedule 1 of the above regulations to end the prescribing of GF foods in primary care. Under this option, no GF foods would be available on prescription in primary care. • Option 3: To only allow the prescribing of certain GF foods (e.g. bread and flour) in primary care, by amending Schedule 1 of the above regulations. Under this option, only certain GF foods would be available on prescription in primary care. Feedback from this consultation is being analysed and updates will be added to the web page in due course. www.gov.uk/government/consultations/availability-of-gluten-free-foods-on-nhs-prescription

NHD CPD eArticles

• Continuing professional development • Answer questions • Download & keep for your files TO VIEW OUR LATEST eARTICLE CLICK HERE . . .

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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

• 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 . . .

Allergy and Free From Show 7th-9th July Olympia, London www.allergyshow.co.uk/london Kindful Eating Working with Children and Families 13th and 14th July Nutricia free symposium Manchester Email: lucy.aphramor@gmail.com

To place a job ad here and on www.dieteticJOBS.co.uk please call 01342 824023 dieteticJOBS.co.uk

DIETITIAN SENIOR I - GIBRALTAR HEALTH AUTHORITY £36,970 to £44,149pa Now is your opportunity to sample the Mediterranean way of life. Gibraltar. We are looking for an enthusiastic, experienced and highly motivated Senior I Dietitian, with a broad-based 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. You would be part of a team of four highly experienced dietitians who would provide you with clinical supervision and support. The appointment will be on contract terms for a period of five months to cover a period of maternity leave. Relocation assistance provided. Passages payable in full and subsidised accommodation. Please contact Ms Melanie McLeod, Senior Dietitian Tel: 00350-20072266 ext 2199 or email melanie.mcleod@gha. gi. Application Packs are obtainable from the Recruitment Section on Tel: 00350-20072266 ext 2081, email: hr@gha.gi; Closing Date: 14th July 2017 SPECIALIST DIETITIAN - TEAM LEADER (WEIGHT MANAGEMENT) - SOLUTIONS4HEALTH £31,696 - £41,373 depending on experience Solutions4Health are looking for a full-time permanent Lead Dietitian who will provide leadership and operational management and take overall accountability for delivering project outputs and outcomes of the specialist weight management service across Peterborough. The post holder will be responsible for staffing arrangements and will be accountable for the overall performance of the services. The post holder will ensure services are delivered and developed to provide high quality, safe and effective packages of

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support that respond to the needs of the client and have a positive impact on the wider community in accordance with contractual obligations and the philosophy of Solutions4Health. Our specialist service takes a psychological approach to weight management, including behavioural change, dietary advice and guidance on physical activity. The post holder will work within a multi-disciplinary team (community/primary care) to develop and deliver S4H programmes on weight management in Peterborough. Please send your CV and covering letter to: recruitment@ solutions4health.co.uk; Closing date: 26th July 2017 LEAD DIETITIAN BAND 7 - KEELE UNI, STAFFS Circa £36k dependent on experience We are seeking an experienced Dietitian with a recognised qualification in Dietetics to support our Director of Clinical Services and Research, Dr Juli Crocombe, and join a growing team of passionate autism professionals who share our vision. This is a full-time permanent position and a once-in-a-lifetime opportunity for an experienced and driven clinician to really make a difference to the lives of autistic children and their families. Established in 2000, Caudwell Children is a national charity with 17 years’ experience of providing practical and emotional support for thousands of disabled children each year. Now is the time to put our experience to good use and contribute to the global conversation regarding autism through the development of our iconic purpose-built therapy and research centre within the grounds of Keele University, and the introduction of a ground-breaking multidisciplinary clinical service and family support programme. Please email your CV to: recruitment@caudwellchildren.com. For a full job description visit: www.caudwellchildren.com/cms/ wp-content/uploads/2017/06/Job-Specification-LeadDietitian.pdf; Closing date: 28th July 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.

The Team at NHD would like to thank Neil for all his work on the magazine over the years. His contribution, support and encouragement have been invaluable.

Dear Reader, It has been a wonderful journey, but the time has come for me to finally step aside from NHD’s Final Helping column. In this last column I have decided to indulge myself with some memories of my 50-plus years in Dietetics. As a regular reader, you may be familiar with some of them. First up has to be when I received the letter in 1966 from Mrs Muriel Westland at the University of Surrey offering me a place on the Nutrition and Dietetics course. My life would have been completely different without that opportunity and I have always been eternally grateful. During my Final Year dissertation on Fitness and Fatness in 1969/70, I arranged with Chelsea Football Club to go along to Stamford Bridge on four separate occasions to assess their first team players. Chelsea went on to win the FA Cup for the first time that season. Alongside this memory is that of meeting my external assessor. When I was informed it was to be none other than Elsie Widdowson, I was thrilled but somewhat terrified! Many years later in 1995 I was asked to second her nomination for an honorary degree at Salford University. She was a quite an amazing lady and it was a wonderful honour for me to be asked and to attend the subsequent degree ceremony. My first job after leaving University was as a VSO Food Consumption Survey Team Leader in Zambia on a three-year UN/FAO Programme. In my second year there, I lived in an isolated village in the Eastern Province for six months as a ‘Nutrition Implementation Officer’. It was an amazing experience and made me realise that I should take nothing for granted and appreciate the subsistence way of life of the Mutondo villagers. Back in the UK, I applied for a job as a dietitian at Ragdale Hall Health Hydro

which was run by Slimming Magazine. I got the job, and at the interview, I met my future wife. It was a whirlwind 18 months, first as a dietitian, then as Personal Assistant to the Managing Director in London and, finally, back to Ragdale Hall as the Manager! I married my Beauty Therapist wife in 1977 and have three daughters, all born at the Victoria Hospital, Blackpool, where I subsequently worked. Moving into the NHS was quite different. As the Head of what was initially a small Department, I was able to expand my interests and activities in the field of Weight Management and Eating Disorders. I was also able to become more involved with the British Dietetic Association, the Department of Health and the then Health Professions Council. I was elected onto the BDA Council as an Ordinary member and sat on a number of committees, including organising the National Conference. Following on from my work with the BDA, especially in relation to founding and editing the publication Adviser, I was made a Fellow of the Association. I was also the Editor of NHD for a number of years. During this time, I have made many friends and met with many colleagues within the profession (maybe it helps being a man!) and have completely exceeded any schoolboy aspirations. It has been a wonderful journey. Thank you to everyone involved, particularly latterly the staff at NHD. I shall now be playing a lot more tennis, having recently had (see pic) coaching from two former Davis Cup players! Thank you for the memories and good health to all. Neil www.NHDmag.com July 2017 - Issue 126

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