Network Health Digest - February 2018

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

NHDmag.com

February 2018: Issue 131

PANCREATITIS

& DIETARY MANAGEMENT

MALNUTRITION CRITICAL CARE & ECMO INSECT PROTEIN EXPLAINED METABOLIC DIETETICS

Autism: diet and nutrition pages 23-26

*Vanilla, strawberry and banana

REFERENCES 1. Data on file. Abbott Laboratories Ltd., 2017 (Sensory research and evaluation: PaediaSure Plus vs. PaediaSure Compact).

2. Data on file. Abbott Laboratories Ltd., 2017 (Sensory research and evaluation: PaediaSure Compact banana flavour and PaediaSure Compact strawberry flavour).

Date of preparation: July 2017 ANUKANI170158

GIVE THEM A LITTLE TASTE FOR ADVENTURE. Not only does it taste fantastic, PaediaSure Compact packs balanced paediatric nutrition (and 27 years of PaediaSure experience) into just 125 ml. And it comes in three great-tasting flavours.*1,2 How else could they reach Neptune?

PAEDIASURE COMPACT. HELPING KIDS BE KIDS AGAIN.

CONTENTS

13 COVER STORY Pancreatitis and dietary management

6

News

35 ENTOMOPHAGY

8

Obesity update

The benefits of insects in nutrition

Latest industry and product updates

Where are we now?

17 SUGAR TAX What we know so far 19 Malnutrition matters

An individual perspective

41 Healthy weight management

Words, weight and ethical autonomy 46 Face to Face

With Pamela Mason, Nutritionist 48 IMD Watch

A spotlight on metabolic dietitians 52 Freelance practice

Finding your niche

23 AUTISM IN CHILDREN The practical management of dietary issues

54 Mindfulness

Wellbeing & productivity

58 Events, courses

& dieteticJOBS

Diary dates & careers

27 Preterm infant feeding

Information and advice 31 Critical care

Feeding patients whilst on ECMO

59 Dietitian's life

by Sarah Howe

Copyright 2018. 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

4

Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

www.NHDmag.com February 2018 - Issue 131

@NHDmagazine ISSN 2398-8754

FROM THE EDITOR

WELCOME Emma Coates Editor

Emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics.

NHD and British Lion Eggs Competition Write an article for the chance to win £250 in shopping vouchers!

Turn to page 40

Welcome to the first issue of NHD for 2018, a year for much celebration as our beloved National Health Service reaches another milestone in its history. On 5th July, the NHS will be 70 years old and like our favourite wise old great aunt or granny, she remains part of our lives, providing support and advice when we need it most.

However, despite her age and regardless of the relentless media coverage discussing her challenges, the NHS is by no means ready to retire. Whilst the service is under pressure, it survives through constant change and innovation.

Our February issue reflects on some of the initiatives and changes that have occurred in recent months and years, as well as offering practical information for current management of patients. We also look at some innovative ideas and options for future dietary trends and management.

In our review articles, we welcome back Kit Kaalund Hansen, who looks at the impact of the sugar tax and what we know so far. A governmental initiative, which was brought into effect in 2017, Kit discusses the changes patients have really noticed as a result. We also review the status of obesity and its management as Emma Berry takes us through an update of statistics, initiatives and management.

Rebecca Gasche returns with an article detailing the management of pancreatitis for our Cover Story, both acute and chronic, looking at the current evidence for managing both patient groups.

Emma Derbyshire brings us a practical overview of preterm feeding, talking us through the current information available for parents. We also have a practical guide from Maeve Hanan for managing patients with feeding issues relating to Autism. Maeve has compiled an overview of the common issues and approaches for management.

The ‘o’ words and their role in weight management, what could that mean? Lucy Aphramor also returns this month to share another perspective on weight management. In her article, Lucy discusses the words and language used in weight management; and their impact on patients.

The term ‘good grub’ can be used to describe a roast dinner or a decent deli sandwich; however, Claire Chaudhry has taken this to a completely new place in her article this month. Insect protein has been a feature of diets globally for thousands of years; however, it has become a source of interest for modern day food manufacturers. Claire investigates this recent trend and digs for the nutritional information.

Could 2018 be the year to start a new career path for you? This month, Suzanne Ford has knitted together a great insight in to the various career options for dietitians in Metabolics, a specialist area of Dietetics that offers a wide range of patient groups, product types and plenty of opportunities for research. We are pleased to announce two new regular columns that will be of much interest to you: freelance work in Dietetics from Priya Tew and Malnutrition Matters from the BDA’s Old People’s Specialist Group (OPSG).

As always, there is too much to mention in my Welcome, so please read on! I am off to enjoy a cup of tea and a cricket flour brownie. It’s the future!

Emma www.NHDmag.com February 2018 - Issue 131

5

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

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INSIGHTS FOR 2018 It’s that time again. Another year and an emergence of new food and nutrition trends. So, what’s likely to crop up in 2018?

I attended the Food Ingredients Conference in Frankfurt at the back end of last year and several themes were apparent. So, here’s what seems to be trending at the moment…

Caring about food production We now not only want to know about how our food is produced in the sense of processing methods used, but also how food production impacts on the environment too. Sustainable is a key trend that is showing no signs of subsiding in 2018 or indeed the near future. So, sustainable and innovative farming and food production methods certainly seem here to stay.

Clean labels Yes, it’s that term again. People are fast becoming fed up with over information.

This, coupled with fast-paced lifestyles, a quick glance at a product and we want to know what it’s all about in a nanosecond. Simple and clean food labelling, coupled with appropriate packaging, now seems to be a must.

Protein possibilities Alternative sources of protein is a big and steady-going trend. Plant-based proteins, including the likes of pea protein, are emerging within the food market.

We are also likely to see a surge in plant-based dining. That said, trials testing the biological effects of plant-based diets are only just coming through. So, we need to be weary that fast-paced expansion of this sector does not surpass the science. In doing so, there could be nutritional ramifications.

Big on colour This was a humongous market sector at the Global Fi Conference. I would ask, do we really need to colour foods in our modern age to give it added appeal? This also seems to go against the natural trend a tad. Nevertheless, there still seems to be a market for highly coloured products and a large one at that. This is possibly being indirectly fuelled by the likes of Instagram and the upsurge in posting images on social media of the kinds of food and drinks we consume. So, if you fancy eating or taking a snap of a food that is iridescent blue or luminous green, the colourings to do this are out there and now being marketed as natural too.

Drinks with dazzle Since SACN published reduced sugar intake guidance, the beverage market has been fast innovating. From sparkling tea, to alkaline water and turmeric-infused lattes, a whole range of new drink products are coming through. And yes, there is even a new drink to combat the effects of ethanol after a hard night out. What is the evidence-base behind these? For most, the product has come before the evidence. For these to survive, however, in the fast-changing market, research and evidence needs to come hand-in-hand with innovation.

6

www.NHDmag.com February 2018 - Issue 131

NEWS APPG HUNGER REPORT WELCOMED BY BAPEN The All Party Parliamentary Group (APPG) on Hunger’s report ‘Hidden hunger and malnutrition in the elderly’, has been welcomed

by BAPEN and sheds further light on the less than ideal state of nutrition and hydration in this group.

The growing prevalence of malnutrition in the elderly over the last decade is a key message from the report, with the number of hospital admissions over the last decade for patients aged 60 years or above with a primary diagnosis of malnutrition, having increased threefold.

It has been recommended in the report that training and support should be implemented at all levels of care, with staff being trained to use BAPEN’s Malnutrition Universal Screening Tool (‘MUST’), which promotes early identification of older people with a risk of becoming malnourished. It has also recommended that when identified, patients at risk should receive appropriate nutritional support with an aim to improve their condition.

The BAPEN Malnutrition Self-Screening Tool which is available free online, is designed to help people identify their own risk of malnutrition. Further details can be found at www.bapen.org.uk.

SUGARY DRINKS FACE NHS BAN IF ACTION IS NOT TAKEN The NHS is taking action to remove sugary drinks from its shops, vending machines and canteens throughout 2018.

The move has been made as almost two thirds of NHS trusts have now signed up to a voluntary scheme which aims to reduce sale of sugar drinks to 10% or less of all drinks purchased within the outlets throughout their establishments.

The voluntary sugary drinks reduction scheme covers sugary soft drinks, milkshakes and hot drinks with added sugar syrups. Other suppliers who are trading within NHS trusts, such as WH Smith, Marks & Spencer, Greggs and the Royal Voluntary Service, have put further restrictions in place. In total 14 national suppliers have signed up to the voluntary scheme.

Warnings have been given to trusts who are yet to sign up, highlighting the need to make changes and take action to reduce sales of sugary drinks by the end of March 2018, after which a ban will be introduced in 2018 instead.

KCL STUDY FINDS SLEEPING LONGER LEADS TO A HEALTHIER DIET Seven hours sleep a night is the recommended minimum for adults.

Taking less than this has been linked with various conditions such as cardio-metabolic disease and obesity, but improving sleep hours can reduce these risks. It is estimated that around a third of UK adults are not getting enough sleep.

A randomised controlled trial has been completed by King’s College London, which considered the feasibility of increasing sleep hours in adults who regularly sleep for less than seven hours per night. As part of the study, researchers also looked at participant’s nutrient intake and whether increasing sleep hours had an impact. Participants in the extended sleep hours group where aiming to sleep for up to 1.5 hours longer per night and given support to implement this. Participants in the control group received no support and continued to sleep as per usual for them.

The study’s findings suggest that sleeping for longer results in a reduced intake of free sugars by 10 grams per day when compared with baseline levels. It was also noted that total carbohydrate intake was reduced in the group who slept longer.

The study has been published in The American Journal of Clinical Nutrition and it seems that sleeping for up to 1.5 hours longer each night is a lifestyle choice that could lead to a healthier diet and help to reduce intake of sugary foods.

Reference: Sleep extension is a feasible lifestyle intervention in free-living adults who are habitually short sleepers: a potential strategy for

decreasing intake of free sugars? A randomised controlled pilot study’. Published on Wednesday 10 January 2018 in The American Journal of Clinical Nutrition.DOI: 10.1093/ajcn/nqx030

www.NHDmag.com February 2018 - Issue 131

7

PUBLIC HEALTH

OBESITY UPDATE: WHERE ARE WE NOW? Emma Berry Associate Nutritionist, Freelance

Emma is working in NHS Research and Development and is a freelance nutrition writer.

REFERENCES For full article references please CLICK HERE . . .

8

The obesity epidemic has been well documented for many years. The World Health Organisation’s (WHO) report documenting the substantial rise in obesity and setting in place a strategy for prevention, was published almost two decades ago.1 This article looks to review the differences in the levels of obesity found within the UK since the report and discusses the most recent policies in place to tackle obesity.

The WHO report1 outlined that the level of obesity was rising at a staggering rate. This rise in level of overweight and obese individuals has also seen an increase in related health issues, such as cardiovascular diseases and various forms of cancer. The WHO report put forward a strategy for preventing a further rise in obesity levels and managing the current high levels found globally.

Obesity has been defined as a high level of adipose tissue which has a negative impact on an individual’s health. There are many ways to determine obesity of an individual or population, these include body mass index (BMI kg/m2), skinfold measurements, waist circumference and waist:hip ratio, many of which are further broken down into various obesity classifications.1 Whilst the definition of obesity has not changed drastically over time, the ways in which adipose tissue can be measured have become more advanced.

Determining body composition is now possible through the use of methods such as Air-Displacement-Plethysmography, Dual-Energy X-ray Absorptiometry, Bioelectrical impedance analysis and more.2,3 Whilst these methods are not used for population measures of obesity but are generally used for academic

www.NHDmag.com February 2018 - Issue 131

studies, it is important to note how advanced technology has become and how these can increase the precision of body composition measures.

The most common way of determining obesity at a population level, is through using BMI (kg/m2).

Being defined as clinically obese is when an adult individual’s BMI is over 30kg/m2.4 When the WHO report was released in 2000, 21.5% of adult men and 21.8% of adult women were classified as obese in England.5 In Scotland, 22% of adult men and 26% of adult women were found to be obese in 2003.6 The most recent figures have demonstrated that obesity rates have increased, with 27% of men and women now classified as obese.4 In Scotland, obesity is also rising steadily with 29% of men and women now classified as obese, based on findings of the 2016 Scottish Health Survey.7 Although the adult level of obesity looks to still be increasing, childhood obesity seems to be holding steady. In England, 9% of children in Reception year were classified as at risk of being obese in 2015/2016, compared to 10% in 2006/2007. 20% of children in Year 6 were at risk of being obese in 2015/16, which is slightly higher than the 17% who were identified as being ‘at risk’ in 2006/07. However, it is believed that

this figures from 2006/2007 were underestimated due to a poor level of participation.8 In Scotland, childhood obesity has remained around the same level for the last decade. In 2015/16, 10% of children in Scotland's Primary 1 school year were at risk of obesity, with the same figure having been recorded in 2006/07.9 Unfortunately, there are no recent statistics for older children in Scotland alone that would allow us to determine if this age group is also remaining steady for obesity figures. However, overall for ages 2-15 in Scotland, the percentage of children at risk of obesity is 14%, which is the lowest recorded figure since 1998.7 FUTURE PLANS TO TACKLE OBESITY

In 2016, the UK government published guidance on how they plan to table and reduce childhood obesity.10 This guidance outlines their plans over the coming years to make a long-term sustainable change through engaging individuals, food and drink industries and communities to become healthier. Their action plan includes encouraging industry reformulation to reduce the sugar content in all foods and drinks by 20%, by means of the sugar sweetened beverage tax. They will also be recommitting to the Healthy Start Scheme to ensure that all families with low income have access to nutritious food. Food and drink industries are also being encouraged to develop new, healthier products for consumption and to work with the UK Government to make nutrient labels easier to understand for individuals. They are also aiming to help healthcare professionals in encouraging healthy lifestyles with family and children.

The Department of Health will also be working with Public Health England to ensure that healthy options will be made easily available in all public sector locations. Furthermore, the UK Government will be looking to repeat the success of the Change4life Sugar Smart app by encouraging the development of new technology which could encourage healthier decisions in individuals. In so doing, they hope that the development of this new technology will produce innovative solutions for tackling childhood obesity.

They have outlined a number of aims which specifically target primary schools. These include

encouraging all children to do 60 minutes of physical activity every day, whilst aiming to improve sport and activity programmes in schools. They will also be looking to create a healthy rating scheme for primary schools and to make school food healthier. As well targeting children in primary schools, they are looking to support children in early years’ settings in receiving healthy food through developing revised menus and encouraging these children to meet the physical activity guidelines through an update of the Early Years Foundation Stage Framework.

On the 26th of October 2017, the Scottish Government opened a consultation on the proposed actions laid out in the consultation document A Healthier Future - Action and Ambitions on Diet, Activity and Healthy Weight.11 The document outlined a range of proposed actions which could be taken to improve the level of obesity in Scotland.

These proposals include limiting the marketing and advertisement of unhealthy foods, supporting preventative measures for families, encouraging the reformulation of food and drinks and working with various groups to encourage local support and create more opportunities for healthy lifestyles. The consultation allowed individuals to comment on the proposed plans and suggest new ideas to help encourage an innovative plan to tackle the obesity problem. This consultation closed at the end of January and results will be published in a report.

CLINICAL TREATMENT FOR OBESITY

Although many of the new UK policies outlined look to encourage families and children to pursue healthier lifestyles. The UK adult level of obesity is still seen to be increasing. One method of helping individuals to reduce their body weight is through bariatric surgery.4 The UK currently has a four-tier system in place to treat clinical obesity (shown in Figure 1 overleaf). Bariatric surgery is the final tier, taken when all other options have not been successful.12 There are various different types of bariatric surgery performed within the UK, the most commonly of which being gastric band, gastric bypass and sleeve gastrectomy.13 www.NHDmag.com February 2018 - Issue 131

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PUBLIC HEALTH Figure 1: Tiers of weight management for clinical management and treatment12

The number of individuals who have undergone this procedure has steadily increased in recent years. In 2006-2007, 1,951 bariatric procedures took place in England, which rose to 6,384 procedures in 2013/14. However, the figure in 2014/15 appeared to drop slightly to 6,032.4 Although this drop suggests that there is a reduced number of individuals undergoing bariatric procedures, there may be various factors for this; the most recent figures have not been released to determine if there has been a continuation in this trend.

Although these treatments have grown in popularity over the last decade, there are often long-term side effects due to the patient’s reduced ability to consume a normal diet.

Often these individuals can suffer from various nutritional deficiencies and complications, such as Dumping Syndrome.14 Nutritional deficiencies often include iron, thiamine, vitamin E and copper, but many others can also appear.

Nutritional deficiencies which present in postoperative care often depend on the type of surgery performed.14 As the number of people within the UK classified as morbidly obese (BMI of 40 and above) increases, there is a chance that requirement for these procedures could increase 10

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further.4 Therefore, it is important to ensure that these individuals can remain healthy after undergoing bariatric procedures, to reduce the risks of complications and to avoid adding additional costs to the already cash-strapped NHS. Further research is required to ensure that the post-operative care is optimal.

CONCLUSION

Obesity is still a serious problem within the UK. Although the obesity epidemic has been documented for many years, the level of adult obesity is still growing within both Scotland and England. However, improvement is starting to be seen in the level of childhood obesity. Future policies look set to attempt to further reduce the obesity levels, targeting mainly children and families, whilst further encouraging a healthy environment for everyone. However, whilst the encouragement of healthier lifestyles may help to reduce the level of obesity seen within the population, the use of bariatric surgery may become more popular as a treatment for individuals.

Although this could help many individuals, the long-term effects and bariatric diet requires further research to ensure these individuals remain healthy after surgery.

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

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

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NHD0218

COVER STORY

Rebecca Gasche Registered Dietitian, Countess of Chester Hospital NHS Trust Rebecca specialises in gastroenterology Dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.

REFERENCES For full article references please CLICK HERE . . .

PANCREATITIS: AN OVERVIEW OF DIETARY MANAGEMENT In this article, Rebecca looks at dietary advice to help manage pancreatitis in both the acute and chronic form.

The pancreas - a small organ found behind our stomach and below our ribcage - has two main functions which allow for the release of enzymes and hormones to aid the digestion of food. The exocrine function produces enzymes to break down carbohydrates, proteins and fats, and the endocrine function homes the islet cells responsible for the release of the hormones insulin and glucagon, to maintain blood glucose levels.

Acute pancreatitis is a condition where the pancreas becomes inflamed over a short period of time and can occur at different severities: mild, moderately severe and severe (see Table 1). In the years 2013 to 2014, the NHS reported that 25,000 people were admitted to hospital with acute pancreatitis.1 Acute pancreatitis is most commonly caused by gallstones or alcohol consumption, and typical symptoms include severe dull abdominal pain which develops quickly, nausea and/ or vomiting, diarrhoea, indigestion and a feverish temperature.1 A small number of cases are caused by neither gallstones nor alcohol consumption and are labelled as idiopathic.5 Most cases of acute pancreatitis resolve quickly, within a week,1 however, 15-20% of patients will go on to develop the complications previously mentioned as a result of the flare up.3 The aim of treatment for acute pancreatitis is to support the body until the inflammation subsides and

following this, treat the cause of the acute episode (for example, gallstones).5 Chronic pancreatitis differs from the acute form as it is an irreversible and long-term inflammation or fibrosis of the pancreas.6 Chronic pancreatitis can lead to endocrine pancreatic insufficiency, resulting from damage to the endocrine tissue of the pancreatic gland (islets of Langerhans), with failure to produce insulin, causing impaired glucose regulation and diabetes mellitus.

Pancreatic exocrine insufficiency (PEI) may also occur from damage to the acinar cells, with failure to produce digestive enzymes, causing malabsorption.6 Chronic pancreatitis has a higher prevalence than acute, with 35,000 hospital admissions reported between the years 2012-2013.7 Similarly, common symptoms include severe abdominal pain, but further complications include diabetes, pseudocysts and an increased risk of pancreatic cancer.8 If PEI is apparent, symptoms caused by malabsorption may occur such as steatorrhea.

Treatment for chronic pancreatitis consists of managing symptoms of pain - this could be through lifestyle changes www.NHDmag.com February 2018 - Issue 131

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CONDITIONS & DISORDERS Table 1: Characteristics of acute pancreatitis2-4 Mild acute pancreatitis

Moderately severe acute pancreatitis

Characterised by the absence of complications, or organ dysfunction and it usually has an uneventful recovery.

Characterised by local complications and/or transient organ dysfunction which resolves within 48 hours.

or with pain relief medications - and may also require treatments such as enzyme replacement therapy, steroids and surgery.7 DIETARY MANAGEMENT - ACUTE

In most cases of acute pancreatitis (around 80%), dietary management includes supportive care with fluid replacement and controlled initiation of regular intake of diet having a positive response on treating the flare up.9 Patients were traditionally started on a clear liquid diet once abdominal pain had subsided and appetite returned, before moving on to a low fat diet.

However, a study by Jacobson et al found that initiating patients on a low fat diet was as safe as a clear liquid diet and resulted in an improved calorific intake.10 For those suffering from severe acute pancreatitis, nutrition support is essential.11 Historically, total parenteral nutrition (TPN) was used to allow for pancreatic rest. However, the use of TPN has been known to carry risks of its own, such as infection and metabolic disturbances.12 In more recent years, studies looking at the use of enteral nutrition as opposed to TPN have been carried out and the results look promising, showing that enteral nutrition may improve outcomes by decreasing the rates of infection, need for surgical intervention, hospital length of stay and overall total cost of care.13,14 Studies by Jiang et al and Kumar et al report that nasogastric (NG) feeding is a suitable method of enteral feeding, as opposed to nasojejenal (NJ) feeding, as it is as well tolerated by patients and as effective in treating severe acute pancreatitis.15,16 NJ feeding may be indicated in patients suffering from prolonged pain and significant pancreatic necrosis.17 Studies discussing the use of enteral nutrition conclude that it should begin early, as 14

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Severe acute pancreatitis Characterised by persistent organ dysfunction (failure to resolve in 48 hours) and can lead to local complications, such as pancreatic necrosis, abscess, pseudocyst formation and multiple organ dysfunction.

it modulates the stress response, promotes more rapid resolution of the disease process and results in better outcomes.17 TPN is not completely ruled out as a treatment; for patients who do not respond to enteral feeding, who meet adequate requirements, or if enteral feeding is inhibited by ileus, TPN can be an effective second line treatment.5,18 A systematic review by Poropat et al found that there was no beneficial effect of specific enteral nutrition formulas, but did note that their evidence was based on low to very low quality.19 Further research into standard, partially digested, elemental or ‘immune enhanced’ formulations has been identified as a need.5 Poropat et al also found that immunonutrition was generally well tolerated and safe and that results showed a reduction in all-cause mortality, but again the findings were based on evidence of low quality.

In addition to this, the review concluded that routine use of probiotic supplements to enteral nutrition should be avoided on the basis of current available evidence because of safety concerns, and that there is some evidence (again, of low or very low quality) for the effects of nutrition over no nutritional support in reduction of all-cause mortality.19 However, the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines released in 2016 challenges this, stating that the use of probiotics should be considered in patients with severe acute pancreatitis who are receiving early enteral nutrition.32 This was based on a number of RCTs which showed a reduction in infections, sepsis and multiple-organ dysfunction when probiotics were used..33,34 The UK guidelines for acute pancreatitis summarise that there is no benefit from enteral feeding in mild pancreatitis and that these patients have no dietary restrictions. Enteral

PERT (pancreatic enzyme replacement therapy) works by mimicking the physiological conditions of a healthy pancreas, allowing the correct amount of enzymes to be delivered to the duodenum, where they are activated with food allowing it to be absorbed. feeding is indicated in some patients with severe acute pancreatitis and suggests that enteral feeding via NG route should be used if tolerated.5 DIETARY MANAGEMENT - CHRONIC

Upon diagnosis of chronic pancreatitis, the initial dietary advice is to reduce alcohol intake and stop smoking, if necessary.8 Even if alcohol has not been the cause of the pancreatitis, reducing intake, or abstaining completely, can reduce pain and the risk of further complications.7 Tobacco has been linked to contributing to complications associated with chronic pancreatitis, due to pancreatic calcifications and ductal changes20 and, similarly, continued alcohol consumption has been linked to acceleration of progression of disease and an increased risk of malignancy.21 It is recommended that patients are referred to suitable services to help quit smoking and reduce alcohol intake.21 A major consequence of chronic pancreatitis is PEI, with 50% of patients who suffer from chronic alcoholic pancreatitis developing it after 12 years.22 Not all patients will show signs of malabsorption due to PEI (some may only have pain); however, those who do, should be offered pancreatic enzyme replacement therapy (PERT).23 The main symptoms associated with PEI are steatorrhea (stools that are loose, fatty and pale in colour), gastrointestinal pain and weight loss24 and the treatment for these symptoms is to commence PERT. The treatment goals of PERT for PEI are to treat symptoms and improve nutritional status, including increase fat

absorption and reduce steatorrhea, reduce stool frequency and improve stool consistency.25 PERT works by mimicking the physiological conditions of a healthy pancreas, allowing the correct amount of enzymes to be delivered to the duodenum, where they are activated with food allowing it to be absorbed.26 Published treatment guidelines for chronic pancreatitis and pancreatic cancer recommend initiating patients on 40,000 to 50,000 lipase units per meal and 10,000 to 25,000 lipase units per snack,27 but this is often titrated to higher doses depending on symptom control. The amount of PERT may also need to be adjusted depending on the size or the fat content of meals, and patients may split the dose of their PERT if consuming a particularly large meal, for example take some at the beginning of the meal and some half way through.26 It is estimated that a healthy human pancreas produces around 720,000 units of lipase with each meal,26 so really, the usual starting dose of PERT is low in comparison. The supplementation of fat soluble vitamins is also thought to be appropriate in those with PEI.21 Traditionally, it was thought that first-line treatment for steatorrhea was to restrict dietary fat intake to less than 20g per day. However, this is now not recommended, as studies have shown that containing fat in the diet in addition to PERT improves the effectiveness, as the half-life of the enzyme activity is enhanced,28 and one study (although this was a study on dogs, not humans) demonstrated that fat digestion and absorption www.NHDmag.com February 2018 - Issue 131

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CONDITIONS & DISORDERS was higher when enzyme supplements were taken together with a high fat diet compared with a low fat diet.29 Further to this, the inclusion of fat-soluble vitamins from the diet of patients with PEI is of high importance, as these are already malabsorbed30 and often patients present with a low body mass index (BMI) as a result of the malabsorption.24 Patients with chronic pancreatitis also have an increased risk of developing osteoporosis,31 therefore, bone density assessments and healthy lifestyle choices are advised, including vitamin D and calcium supplementation.21 The main role that healthcare professionals play in providing dietary support for chronic pancreatitis is to promote a healthy balanced diet, achieving optimum nutritional status, as well as reducing the symptoms of malabsorption and educating regarding the adverse effects that alcohol and tobacco may have. The management of patients with chronic pancreatitis has improved in the last decade, partly due to more focus on using a multidisciplinary team approach.21

CONCLUSION

Dietary management in pancreatitis remains of high importance, to manage symptoms and improve a patient’s quality of life.

In acute pancreatitis, fluid support and reintroduction of diet once symptoms have improved is an appropriate course of action, but the use of a clear liquid diet is not needed.

In severe acute pancreatitis, early feeding via an enteral form - this can be NG or NJ - is advised and surpasses old evidence of TPN being used as a first line treatment. Further research into specific feeds would be of benefit.

Dietary advice for chronic pancreatitis includes alcohol and tobacco cessation and general healthy eating advice, including calcium and vitamin D sources for bone health. For those patients suffering from PEI, the use of PERT can help to manage symptoms and achieve optimum nutritional status. A multidisciplinary approach is essential for providing patients with the best possible care.

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PUBLIC HEALTH

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

REFERENCES For full article references please CLICK HERE . . .

In March 2016, the government announced that a tax on sugary soft drinks would be introduced in the UK from April 2018, in an attempt to halt childhood obesity, Type 2 diabetes and tooth decay, all of which are preventable and cost the National Health Service billions of pounds each year.1 This article sets the scene for what we know so far.

In December 2016 the government announced plans for a tax on drinks that “have no nutritional benefit and contain more than 30g of sugar per serving”.2 For instance, a can of coke contains 35g of sugar and Coca-Cola are set to bear the brunt of the tax because it currently has no plans to change the recipe of its classic drink.3 The government’s reasoning for implementing a sugar tax was to try and reduce overall sugar intake, particularly in teenagers, and to combat childhood obesity (Parliament, 2016). Unsurprisingly perhaps, the drinks industry reacted by saying that it’s ironic that they’re being singled out when they, in fact, started reducing the sugar content of their products in 2012, and they’ve already set a target to reduce overall calories of sugary drinks by 2020.4 In December 2016, we were given a little more detail on what products would be affected: all soft drinks containing more than 5g of sugar per 100mls and the tax will depend on the sugar content per 100mls. Fruit juices were exempt, but the recommendation is no more than 150mls per day. Milk and yoghurt-based drinks will be exempt due to the worry around low intake of dairy in teenage girls. It was further announced that the money raised will go to Education for School Sports.5 In March 2017, the level of tax was announced. There are going to be two arms: drinks containing 5g of sugar or more will be taxed 18p and the consumer cost will increase by 6p, whereas soft drinks that contain 8g of

sugar or more will be taxed 24p per litre and consumer cost will increase by 8p.6 As already mentioned, the soft drink companies have already taken action to reduce the sugar content of their drinks before April 2018; this might also impact on revenue for the Education for School Sports, as the estimated profit was set at £1 billion (Patrick Collins, The Guardian, March 2017).

The sugar tax was left out of the Autumn 17 Budget due to what I can only assume to be more pressing issues, such as homeland security and the NHS crisis. However, the levy has been welcomed by health campaigners who have argued that fizzy drinks are contributing to the country’s obesity crisis. But where might the sugar tax leave our health service and dietetic practice? In inborn errors of the metabolism, patients who require an emergency regimen are either prescribed a glucose polymer or advised to choose an alternative, i.e. sugary drinks with the carbohydrate equivalent. However, the British Inherited Metabolic Diseases Group advises that all metabolic centres prescribe glucose polymers for all patients requiring an emergency regimen to prevent adverse events.7 In turn, this might put an extra cost burden on GP practices, as standard glucose polymers cost an average of £0.50p per serving.

This is an area to watch and there have been speculations as to whether the sugar tax might also eventually include sugary foods. Time will tell. www.NHDmag.com February 2018 - Issue 131

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

All information correct at the time of print. December 2016

IN ASSOCIATION WITH THE BDA’S OLDER PEOPLE SPECIALIST GROUP (OPSG)

MALNUTRITION: AN INDIVIDUAL PERSPECTIVE Dr Mabel Blades RD Freelance Registered Dietitian and Nutritionist Mabel is a member of the BDA’s Older People Specialist Group. All aspects of food and nutrition interest and enthuse her and the dissemination of information on these topics remains her main career aim in life.

MALNUTRITION MATTERS

Specialist Group

Malnutrition is defined by the British Association for Parenteral and Enteral Nutrition (BAPEN), as ‘a state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on body function and clinical outcome’.1 While most of the focus on malnutrition is on obesity, under nutrition is a major problem in the UK and costs the health and social care budgets billions each year.

There are numerous consequences associated with malnutrition including weight loss, impaired temperature control due to the loss of insulating body fat and increased muscle loss (sarcopenia). Other risks include weakness and fatigue, apathy, depression and self-neglect, impaired immune response, increased tissue breakdown and impaired wound healing, osteoporosis and increased risk of fracture, constipation and anaemia.

ASSESSMENT

The Malnutrition Advisory Group2 describes malnutrition as a Body Mass Index (BMI) <18.5kg/m2 and unintentional weight loss greater than 10% within the last three to six months, or BMI <20kg/m2 and unintentional weight loss greater than 5% within the last three to six months.

The MUST (Malnutrition Universal Screening Tool) is easy to complete, with adequate training support. It is based on five simple steps using a chart to evaluate the scores: 1. Calculate or estimate the patient’s BMI score.

2. Note percentage unplanned weight loss and assign score.

3. Establish acute disease effect and score.

4. Add scores together to obtain overall malnutrition risk.

5. Develop care plan using management guidelines or local policy.

A score of 0 indicates a low clinical risk and repeat screening is recommended. This should be weekly in a hospital and monthly in the residential care, or annually for those in special groups, such as those over 75 years of age.

A score of 1 indicates a medium risk and observations are recommended, including observing and documenting food intake for three days. If the intake is good, then repeat screening is recommended. This should be weekly in a hospital and monthly in the residential care, or every three months for those in the community. If the three-day intake is inadequate, it is recommended to follow local clinical policies.

A score of 2 or more indicates a high risk and treatment is recommended.

Such treatment can include referral to a registered dietitian or nutritional support team, increasing and improving nutritional intake and monitoring by regular MUST screening. (Obviously if death is imminent or nutritional support is detrimental, then such steps to increase intake are inappropriate.) It should also be remembered that people who are obese can also suffer from under nutrition and the impact that this has on health should be considered. While the MUST is commonly used alongside the criteria detailed earlier in this article, there has been an update in 2015 from the European Society of Clinical Nutrition and Metabolism (ESPEN) who issued a consensus statement on www.NHDmag.com February 2018 - Issue 131

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MALNUTRITION MATTERS the diagnostic criteria for malnutrition.2 This consensus recommends: • Individuals at risk of malnutrition are identified by validated screening tools and should be assessed and treated accordingly.

• Risk of malnutrition should have its own ICD code.

• There should be two options for the diagnosis of malnutrition.

1. Option one requires a BMI <18.5kg/m2 to define malnutrition.

2. Option two requires the combined finding of unintentional weight loss (mandatory) and at least one of reduced BMI or a low fat free mass index. Weight loss could be either more than 10% of habitual weight indefinite of time or more than 5% weight loss over three months.

Reduced BMI is more than 20kg/m2 in subjects younger than 70 years and below 22kg/m2 in those older than 70 years.

RESIDENTIAL AND CARE HOMES

Food First has an initiative which trains staff to identify residents at risk of malnutrition and provides appropriate support in care homes.3 In a survey of malnutrition in 2015, it was found that 28% of those in residential homes and 38% of those in care homes suffered from malnutrition.4 PERSON-CENTRED CARE

Behind all of the figures, there are individuals with their varied backgrounds, plus likes and dislikes and they should be at the centre of everything.

Some individuals who are over the age of 80 and who have always been slim who have a BMI which falls in the range of 18kg/m2, can find it both intrusive and upsetting to be encouraged to gain weight, especially for example, when some very elderly patients still like to choose their own food from the local shops. I know one lady who is over 100 years old, who still likes to do just that!

It is not just about assessing those at risk of malnutrition, but doing something about it . . .

It must be remembered that obese people can suffer from malnutrition and this should be taken into consideration and is covered to an extent in the consensus statement. Also some older people do wish to lose weight if they are obese for other health reasons and this needs to be properly considered and documented.

Some individuals do not like to be regularly weighed and for them a MUAC (Mid Upper Arm Circumference) is helpful.

IN CONCLUSION

It is not just about assessing those at risk of malnutrition, but doing something about it, which means increasing the nutritional content of a person’s diet in an acceptable and enjoyable manner for the individual.

Whilst oral nutritional supplements have a place, they also need to be regularly reviewed, as sometimes people can find them off putting and after tastes and feelings of fullness stop them from enjoying a meal. This is an area where dietitians can provide appropriate and invaluable advice for each individual.5

References 1 BAPEN (2003). The ‘MUST’ Explanatory Booklet. Members of the Malnutrition Action Group (MAG), a Standing Committee of the British Association for Parenteral and Enteral Nutrition: Edited by Todorovic V, Russell C and Elia M 2 Cederholm T et al (2015). Diagnostic Criteria for malnutrition - An ESPEN Consensus statement. Clin Nutr. Jun 34 (3) 335-40 3 Forbes C (2014). The Food First approach to malnutrition. Nursing and Residential Care. 24th July 4 BAPEN (2015). Malnutrition survey of care homes. December 2015 5 Blades M (2017). The dietitian’s role in the care of older people and malnutrition risk. Dietetics Today. March 2017

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CONDITIONS & DISORDERS

THE DIETARY MANAGEMENT OF AUTISM Maeve Hanan UK Registered Dietitian, Freelance Maeve works as a Freelance Dietitian and also runs the blog Dietetically Speaking.com, which promotes evidence-based nutrition and fights nutritional nonsense.

REFERENCES For full article references please CLICK HERE . . .

Autism is described as a lifelong developmental disability which can present in a range of ways, including cognitive differences, sensory differences, communication differences, social differences and certain medical and mental health issues.1-3 This article discusses the practical management of dietary issues in the context of children with autism.

Autism, although a lifelong disability, is also associated with unique strengths such as good memory of facts, logical thinking skills and awareness of small details.1,3 Some of these differences can present challenges in terms of dietary intake, which can include overeating, undereating, restrictive eating (or avoidant restrictive food intake disorder (ARFID) in severe cases), pica, difficulty with meal presentation or the eating environment, continuous grazing or ritualistic eating.1 MONITORING DIETARY INTAKE AND GROWTH

Dietitians can support a family to maximise the nutritional adequacy of their childâ&#x20AC;&#x2122;s diet; including advice on food substitutes and use of supplements as needed.1 Faltering growth is more commonly seen in younger children with autism; often because of gastrointestinal issues and/or restrictive eating.2 Older children with autism, however, seem more predisposed to becoming overweight; often due to a high intake of refined carbohydrates, sweet foods and savoury snacks and a low intake of fruit, vegetables, wholegrains and fish.2 Although selective eating is an extremely common feature of autism, reassurance should be given if the child is growing well in order to reduce parental anxiety.1 MICRONUTRIENT DEFICIENCIES

Severe autism is associated with lower levels of calcium, iron, zinc, vitamin C,

vitamin B3 and vitamin B6.4 As with the general public, it is also important to consider vitamin D status.5 Correcting vitamin and mineral deficiencies in children with autism using appropriate supplements is advised as a first line treatment, which should be followed by other strategies to improve overall nutritional intake.1 However, achieving the recommended intake of micronutrients may be challenging as supplements may be refused, so a relaxed and pragmatic approach is usually best.1 Unflavoured supplements, such as paediatric Seravit (SHS) can be better tolerated than flavoured versions; but this specific supplement needs to be combined with a fish oil supplement to provide essential or long chain fatty acids (such as Ideal Omega Swirl (Barleanâ&#x20AC;&#x2122;s), Lem-0-3 (Cytoplan), MorEPA and MorDHA (Nutritional Intelligence).2 It is also important to monitor for signs of anaemia in those with a low iron intake; as advice on iron intake and/or iron supplementation may be indicated.6 ENVIRONMENTAL FACTORS

In dietetic consultations, additional time is often needed and it can be helpful to alter sensory aspects of the clinic setting to suit the individual where possible.

For example, if a child with autism is hyper-auditory, it is a good idea to limit the noise in the clinic room by closing windows, or if they are hyper-visual it may be helpful to reduce the amount www.NHDmag.com February 2018 - Issue 131

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CONDITIONS & DISORDERS Table 1: Generally helpful mealtime strategies • Try to keep mealtimes enjoyable and relaxed.

• Set a regular meal pattern, including a maximum length of time for meals.

• Mealtime hygiene - keep the meal environment clean and clear, provide sensible portions, don’t present too many types of food at once.

• Family members to model good eating habits, e.g. everybody eats at least one food from each food group every day.

• Ensure a consistent approach from all family members and carers.

• Use of positive reinforcement when a new food is tried, or when good mealtime behaviour is displayed.

• The ‘parent provide, child decide’ approach can be useful to avoid arguments about food.

• Some people react well to a visual meal timetable or reward charts (without using food as a reward).

• Involving the child in meal preparation, unless this causes sensory overload, in which case it can be better to have meals away from the kitchen to avoid cooking smells and sounds.

• Younger children may react well to messy play and making pictures out of food.

• Older children and teenagers may respond well to a ‘scientific approach’ such as discussing nutrition facts, discussing psychological strategies, having tasting sessions, setting food related goals, etc.

• Placing their feet on the floor or on a stable chair to feel grounded and so reduce anxiety.

• Avoid: - too much coaxing or pressure to eat (as this provides attention to an unwanted behaviour); - force feeding or hiding food (which can result in conflict or the loss of trust); - giving too many options; - grazing’ throughout the day or filling up on fluids; - reacting negatively if food is spat out (better to praise that the food was tried in the first place).

• Desensitisation as discussed opposite.

of visual stimuli in the room (bright lights, colourful wall displays, etc.). Equally, if a child is hypo-visual it may be useful to incorporate visual elements into the session.

In terms of mealtimes, some children with autism eat more when sitting with other people, whereas others prefer to eat by themselves.4 Similarly, some children find it difficult to eat in a noisy atmosphere, but others eat better when there is music or a video playing in the background.2,6 Extra consideration may also be needed to account for sensory preferences for: specific cutlery or utensils, foods of specific colours or textures and overall food presentation.1 For example, children with autism often dislike mixed textures, such as milk and cereal together, so may prefer to have these presented separately.1 If eating in a different environment (such as a restaurant), it can be helpful to prepare in advance by discussing where they will be going, who will be there, where they will be sitting and what they could speak to people about at the table.6 24

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COMMUNICATION CONSIDERATIONS

Similar to environmental adjustments, it is important to adapt communication accordingly.

Depending on the client, this may include the use of visual prompts, limiting the use of hand gestures, not overloading with instructions, using short closed questions, speaking more slowly, awareness of nonverbal communication, using consistent and specific language to discuss food, limiting ambiguous humour and sarcasm and incorporating the child’s interests and strengths into the session.7 Useful visual resources include: reward charts, food planners, picture books, ‘Social Stories’ (developed by Carol Gray in 1991), the Picture Exchange Communication System (PECS) and ‘Dinner Winner’ trays.6-7 MEALTIME ADVICE FOR PARENTS

Reducing stress at mealtimes and creating a positive food environment is crucial.1,4 Successful strategies vary a lot between individuals, but sensible tips are outlined in the Table 1.2,6

Figure 1: An example of ‘food-chaining’

Table 2: Sensory characteristics of food exchange system (from page 180 of The Manual of Dietetic Practice, 5th Edition)2 Acceptable food

Colour

Shape

Texture

Taste

Temperature

Exchange foods

Bacon

Pink –brown

Rounded flat

Firm crispy

Salty

Hot

Pastrami Gammon Prawns

Cheese balls

Orange

Round

Crunchy

Salty

Ambient

Homemade salted popcorn

DESENSITISATION TO NEW FOODS

This gradual approach, also referred to as ‘foodchaining’, introduces new foods by linking from a current ‘safe food’ to a similar food (such as a different brand or shape of bread stick) and continuing in a stepwise manner as outlined in Figure 1 above.6 This includes encouraging the child to touch, smell, lick and taste new foods and praising these actions even if the new food isn’t tolerated.6 It is also important to explain that this process can take a long time. In some cases, significant progress can include accepting being in the same room as a certain food, or accepting what’s on the plate without eating it. It is usually sensible to avoid ‘contaminating’ accepted foods with new foods by presenting them on separate plates and starting with a small amount of a new food then titrating upwards if tolerated. Occupational

therapy-led oral desensitisation programs can also be very useful,1 as these can include the use of brushes, massages, blowing bubbles, use of chewy tubes and ‘chewlery’.

A ‘food exchange’ is a similar approach where a food’s features are assessed and a food with similar qualities is exchanged for this (see Table 2).

PSYCHOLOGICAL STRATEGIES

As with any dietetic consultation, it is important to use motivational interviewing techniques to support behaviour change, such as, rolling with resistance, accurate empathy and being led by the client and/or their family. It is also key to set realistic goals in the context of autism, rather than trying to resolve all food-related issues.1 With family members and some older children, it can be useful to explore psychological strategies www.NHDmag.com February 2018 - Issue 131

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CONDITIONS & DISORDERS Table 3: The ABC of behaviour A - Antidote (i.e. triggers)

A baby cried, or a new food was touching a ‘safe food’, etc.

B - Behaviour (i.e. what happened)

Child threw the dinner plate, or ran away from the table, etc.

C - Consequence

Parent threw food in the bin, or there was an argument about the meal, etc.

Table 4: Examples of nutritional advice Issue

Nutritional advice

Constipation

Advice on gradually increasing fibre and fluid intake.

Tooth decay

Advice on reducing sugar intake, aiming to limit sweet foods to after meals and limiting overall snacking.

Overeating

Strategies to encourage movement, reduce portions, reduce snacking and increase fruit, vegetable and fibre intake.

Undereating

Strategies to increase portions and high energy high protein advice.

Potential food hypersensitivity

Dietary assessment, use of food and symptom diary and advice on nutritionally balanced exclusion trials if indicated. If requested by the family, exclusion trials of gluten and casein should be supported by a dietitian to ensure nutritional adequacy; as long as the limited evidence base and pros and cons of this approach are discussed with the family in advance (based on an individual dietary assessment).1

such as cognitive behavioural therapy to decatastrophize fears related to food. Another relevant strategy is the ‘ABC of behaviour’ (as outlined in Table 3); this can help to identify whether the child is reacting to the food itself or to another environmental factor.

Keeping a food diary can also help to identify patterns of food refusal. A detailed food diary can include the time, what was eaten, where it was eaten, volume consumed, response to the meal, who was present, other environment factors, etc.6

a detailed dietary assessment. For example, The BDA report that standard healthy eating guidelines are often inappropriate for those children with autism who have an extremely limited diet (i.e. those who eat less than 20 types of food).1 It is also important to explore the underlying issues for eating difficulties; such as sensory or social differences.6 Some common nutritional issues, which may need to be considered on a case by cases basis, are listed in Table 4.1,6

MULTIDISCIPLINARY WORKING

CONCLUSION

It is crucial that all goals are clear and consistent between everybody involved in the child’s care, including the client, family members and carers. Autism outreach teams and The Autism Society can provide great support and resources for families. Working with speech and language therapy for those who have poor oral motor skills or extreme oral sensitivity can also be very important. Occupational therapists can assess and clarify the child’s sensory profile and develop a suitable desensitisation programme.1 INDIVIDUALISED ADVICE

As each case is unique, it is important to provide an individualised treatment plan based on 26

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To account for the numerous differences which can occur in autism, there are many aspects of dietary care to consider. This can include monitoring growth and nutritional intake, correcting micronutrient deficiencies, making environmental and communication adaptations, encouraging positive and relaxed mealtimes, supporting with desensitisation to new foods and the use of psychological strategies.

Ensuring that treatment is individualised and working closely with other members of the multidisciplinary team, as well as family members, are also key aspects of providing consistent patient-centred care in order to improve dietary outcomes for children with autism.

PAEDIATRIC

FEEDING PREMATURE INFANTS 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

REFERENCES For full article references please CLICK HERE . . .

There is general information available about how to feed infants per se. But what if an infant is born premature? How do feeding recommendations vary? Publications don’t tend to include distinct recommendations for preterm infants and there is a need to separate guidelines for this group of children. This article takes a look at what information is available and how to first feed premature infants.

A premature infant is typically defined as a baby that is born before 37 weeks of pregnancy.1 So there can be different ‘levels’ of prematurity as such. Typically, healthy preterm infants born from 34 completed weeks and onwards can be weaned using the same feeding guidelines as full-term infants.1 For those who are born before this and who are premature or sick, BLISS feeding guidance needs to be followed.2 This article focuses on how milk and solid foods are best introduced to preterm infants.

MILK FEEDS

If possible, breast milk is a perfect first food for preterm infants. This is thought to help protect the baby from infections, including those of the gut which they are naturally more predisposed to.3

It is also easy to digest and contains the key flavours, hormones, nutrient and growth factors that a young baby needs.3 If it is not possible to feed from the breast, support and advice should be provided to help mothers express their milk.3 If a preterm baby is bottled fed, the healthcare team usually prescribe preterm formulas. Most infants tend to have moved on to full-term formulas by the time they are discharged from hospital.4 The range of nutrients that a premature baby has needs to be carefully balanced to suit their immature digestive system whilst meeting the needs of their growing body.4 Research shows that a number of key nutrients, including the likes of iron, zinc, copper, selenium, manganese, iodine,

Table 1: Nutritional differences - full term versus preterm13 Term infant 37-40 weeks gestation, where intrauterine environment has been appropriate Body weight of >2.5kg, doubling within the first year of life Skeleton to protect from the physical environment, and by one year of age, supporting the infant Musculature sufficiently developed to allow inflation of the lungs, breastfeed and move Insulating layer of fat around organs and under skin, also providing protection and an energy reserve Sufficient iron stores for first three to four months Structurally and physiologically mature digestive system to process nutrition A brain that will co-ordinate processes and communicate its needs

Preterm infant 24 weeks gestation Body weight of around 600g Skeleton inadequately calcified and at high risk of fracture Musculature insufficiently developed to inflate lungs No adipose stores to provide protection, insulation or energy reserves No iron stores A digestive system whose structure cannot support the transit of food and has not developed adequate enzyme support to digest adequate nutrition Primitive and underdeveloped brain

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PAEDIATRIC Table 2: Summary of main ESPGHAN recommendations for preterm enteral feeding10,12 Nutrient Fluid ml/kg/day Energy kcal/kg/day

Recommended intake 135-200 110-135 Body weight <1kg - 4.0-4.5 Body weight 1-1.8kg - 3.5-4g 69-115 66-132 120-140 60-90 400-1,000 20-25 35-100 2-3 from 2-6 weeks of age (from 2-4 weeks of age in extremely low birth weight infants)

Protein g/kg/day (depends on infant’s body weight) Sodium mg/kg/day Potassium mg/kg/day Calcium mg/kg/day Phosphate mg/kg/day Vitamin A µg RE/kg/day Vitamin D*µg/day (not per kg/day) Folic acid µg/kg/day Iron mg/kg/day Table 3: Pointers for feeding preterms

When the time is right, let them have a go at feeding themselves - they often cope with more difficult textures better if they are doing the feeding.

Simple finger foods can work well for preterms. Try very ripe slices of fruit or soft fingers of buttered toast.

Change the consistency from smooth to being more textured and lumpier gradually. Cooking in batches at home and grading the consistency can make this easier to do.

If baby gags or splits out lumps reduce the consistency a touch and then try again a few days later.

Try not to be anxious as a parent or feeder. Babies can pick up on this and feel anxious themselves. Give them a smile and plenty of encouragement.

Try not to fill baby up on too much milk before their meals. Try giving this after meals as more of a top up it they want it - during weaning most babies natural reduce their milk intakes.

Source: Adapted from NHS (2017)8 Cambridge University Hospitals.

chromium and molybdenum, have critical functions and need to be supplied in adequate amounts to premature infants.5 NUTRITIONAL GUIDELINES

No UK guidelines exist for enteral feeding of preterm infants and so international guidelines are used.9,10,11 Table 2 summarises the main ESPGHAN recommendations.10,12 SOLID FOOD

Complementary foods (CF) include all solid and liquid foods other than breast milk or infant formula.6 The British Dietetic Association7 follows BLISS recommendations2 that five to eight months after a premature babies ‘actual’ birth date is a good time to introduce CF. This ‘window’ is thought to help capture the period when sensitive acceptance of solids are not missed.1 Within BLISS guidance2 it is also recognised that every preterm infant is different, though very

few tend to be ready to wean at five months, or need to wait for as long as eight months. Most premature infants do best if the introduction of CF is delayed until after three months from their estimated date of delivery. By waiting, this enables the sufficient development of motor skills that will help them along when weaning.2 This period is also very important in terms of taking time to also observe individual infant cues and monitor each child depending on his or her developmental level.1 CONCLUSION

In conclusion, whilst we know much about how best to feed full-term infants, we must not overlook the needs of preterms. Preterms are a special group that need extra support - right from breastfeeding and through the process of CF. As the weaning window is somewhat broader for preterms parents may need help deciphering when the right time to begin weaning is and how to best pace this for their child. www.NHDmag.com February 2018 - Issue 131

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Intensive

High protein intensive enteral nutrition for the ICU For the dietary management of patients with or at risk of malnutrition, in particular critically ill patients including trauma, surgery, sepsis or burns. > > > >

1.2 kcal/ml tube feed 10g protein per 100ml Nutritionally complete in 1000ml Optimal ratio of energy to protein

Many complex patients Hundreds of drugs Various therapeutic pathways Bearing high level of responsibility Critical decisions to make

1 nutrition solution

For further information please contact Fresenius Kabi tel: 01928 533516 fax: 01928 533520 email: scientific.affairsUK@fresenius-kabi.com Date of preparation: June 2017 EN01360a

CLINICAL

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.

(Twitter @BdaCare and Facebook page)

REFERENCES For full article references please CLICK HERE . . .

CRITICAL CARE: FEEDING THE ADULT EXTRACORPOREAL MEMBRANE OXYGENATION PATIENT Extracorporeal membrane oxygenation (ECMO) is a highly specialised life support technique whereby a machine is able to temporarily support a person’s cardiac and/or respiratory systems after surgery or life-threatening illness. This may also be referred to as Extracorporeal life support (ECLS).

An ECMO machine is a form of temporary life support which uses a cardiopulmonary bypass circuit similar to the equipment used during a heart-lung bypass operation. There are two most common forms of ECMO, both of which involve blood being removed from the venous system and oxygenated outside the body.

• Venovenous (VV) ECMO is used for respiratory failure returning oxygenated blood to the venous system near the right atrium.

• Venoarterial (VA) ECMO is for those with severe cardiac failure; therefore, returns the oxygenated blood to the arterial system.

Royal Brompton and Harefield Trust (RBHT) is one of five commissioned centres nationwide funded to offer VV ECMO for adults with severe acute respiratory failure along with Guy’s and St Thomas’ Hospital NHS Foundation Trust (FT), Papworth Hospital NHS FT, University Hospitals of Leicester NHS Trust and University Hospital of South Manchester NHS FT.1 VA ECMO does not have the same commissioning process.

Patients needing specialist support are referred (see Table 1 overleaf) by other hospitals to the regional VV ECMO centre. Once recovered, patients return to the referring hospital for ongoing support and safe effective discharge home.

Figure1: VV and VA ECMO

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CLINICAL Table 1: Referral indicators and contraindications for VV ECMO retrieval1 Indications: Age ≥16 years Potentially reversible severe acute respiratory disease typically associated with severe hypoxaemia (e.g.

PaO2/FiO2 <13.3kPa), severe hypercapnic acidosis (e.g. pH<7.20) despite conventional support No limitation to ongoing life-sustaining treatment Murray score ≥3.0 (consider referral if ≥2.5 and rapid clinical deterioration) OR uncompensated hypercapnoea with pH <7.2 Adequate arterial blood gases cannot be achieved using lung protective tidal volumes and pressures Contraindications: Intracranial bleed (current or recent) High pressure (peak inspiratory pressure >30 cmH2O) and/or high FiO2 (>0.8) ventilation for more than seven days (relative contraindication) Other contraindication to heparinisation

RBHT uses a unique online system called ‘Hospital to home’ to support this process and to enable MDT discussions across both sites throughout a patient’s pathway.1 Hospital to home is aiming to be built upon and extended to VA ECMO in the not too distant future.

ECMO has been used increasingly in the past three decades; greatest demand was seen with the onset of swine flu in 2009, enabling the support of patients with severe cardiopulmonary failure who have been unresponsive to conventional therapies.1 Nutrition support for adults receiving ECMO has not been well researched or documented.

There are ASPEN Neonate ECMO guidelines, but only small scale retrospective observational studies on adults. With the absence of available guidelines, current practice for ECMO patients is thorough assessment and considerations similar to any critically ill patients, all of which will generally be based on an ICU. Nutrition is paramount to minimise catabolism and support recovery in critical illness. Sufficient nutritional support is associated with a reduced incidence of infections, costs and a length of ICU stay.2,3 Despite known benefits of nutritional support, meeting ICU patients’ requirements can be very difficult.3,4 FEEDING METHOD

Historically, concerns for the negative effects of enteral nutrition in patients receiving ECMO has led to withholding enteral nutrition in this patient group in many ICU centres.5 Anxieties 32

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continue to exist regarding the safety, timing and adequacy of nutrition in this patient group.

A recent retrospective local audit (presented at 2017 ESICM conference) of 80 patients at RBHT found that nasogastric feeding within 24 hours of initiating ECMO is safe and well tolerated.

These results are inline with current critical care guidance that enteral nutrition using a feeding tube and initiated within the first 24 to 36 hours is safe and well tolerated.6 Enteral nutrition is the preferred route, but parenteral nutrition should be initiated for supplementary or total nutrition provision when enteral nutrition is not adequate as per Table 2 overleaf.6 REQUIREMENTS

There are ongoing discussions within the critical care profession regarding methods of calculations and optimal macro and micro nutrient provision to aim for. The method or equations for calculating both energy and protein requirements tends to be centre specific regarding what equations should be used on which to base estimations.

INTACT trial 2014 found that early provision of higher energy and protein intakes predicted increased mortality risk in 78 patients with acute lung injury.7 Patients on ECMO are in an acute phase and highly catabolic phase of care.

Nevertheless, optimal outcomes are seen when relatively low protein and energy are provided for the first few days, increasing recognition that nutrition provision is beneficial, but not

Sufficient nutritional support is associated with a reduced incidence of infections, costs and a length of ICU stay. necessarily aiming to meet the full requirements.

There is a careful balance of not under-feeding, but also not over-feeding due to potential harm, such as increased ventilator requirements, deranged liver function and risk of ischaemic bowel. We currently build up intake over the first few days following admission, aiming to meet requirements by day three to four, increasing this further as the patient continues to recover and progresses towards rehabilitation.7 Protein requirements on ECMO are thought to be similar to other nutrient loss processes, such as renal replacement therapy or pressure ulcers.

Therefore, adequate protein is important and the use of both higher protein target intake and high protein feed formulations. Micronutrients or immune modulating agents have unknown impact, so regular monitoring and supplementing as indicated inline with all patient requirements is necessary. There is ongoing research into specific vitamins and minerals, for example, vitamin D supplementation in those who are deficient is thought to have positive outcomes.20 The microporous membrane in the oxygenator can be compromised by the accumulation and potential blockage by IV fat for example from parenteral nutrition. However, this complication is rare, hence why the anaesthetic propofol is frequently used for sedation. Propofolâ&#x20AC;&#x2122;s lipid solubility and quantities needed to support ECMO patients should be considered; calories from propofol may need to be accounted for at roughly 1.1kcal/ml.6 This in turn can compromise nutrition provision to avoid overfeeding of patients who are receiving both nutrition and propofol.

When considering nutrition support in the ICU, certain comorbidities should be taken into consideration, for example, pre-existing liver, gastrointestinal or renal dysfunction is an important aspect when contemplating nutrition support and can alter the choice of enteral nutrition formulas selected for delivery.

Obese patients also require high protein and relatively low energy provision as per ASPEN guidelines.8 Critical illness associated endocrine response in the form of insulin resistance and hyperglycaemia mean close monitoring of blood glucose levels and sliding scale insulin management is standard practice for all intensive care patients.6 GASTROINTESTINAL AND FEED TOLERANCE

Gut permeability and motility is a key concern as there is thought to be reduced gut perfusion and absorption. Gut motility can be compromised by heavy sedation and/or paralysis, therefore, laxatives are routinely given to ECMO patients.

Prokinetics are given when indicated, based on local gastric residual volume aspirates guidelines. However, one study found 95% of patients required prokinetics within the first 48 hours.9 Gut perfusion can be compromised for ECMO patients as a result of haemodynamic instability, fluid resuscitation, vasoactive agents, hypoperfusion, and cardiac failure. Therefore, ECMO can be associated with risk of mesenteric bowel ischaemia.

Feeding intolerance has been reported in up to 60% of patients in the ICU, as seen by gastrointestinal disturbance such as vomiting, diarrhea, or abdominal distension.10 Intolerance is thought to be multifactorial, with contributing factors including impaired function of the enteric nerve and smooth muscles of the gastrointestinal tract, inflammation, surgery, medications, electrolyte imbalances, hyperglycaemia, sepsis, increased cranial pressure and the presence of disease itself.10 The NUTRIREA 1 trial explored the effect of not monitoring residual gastric volume in adults receiving mechanical ventilation (MV) and early enteral feeding, and showed that there was no increase in the incidence of aspiration or related complications.11 A study found that up to 63% of www.NHDmag.com February 2018 - Issue 131

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CLINICAL Table 2: Audits of feeding methods for ECMO patients Audit

Patient requirements

Retrospective audit of 86 ECMO patients14

10% of patients needed TPN for three days or more.

80% of patients needed enteral nutrition every day for two weeks following admission.

Patients started on enteral nutrition had better tolerance of full enteral nutrition.

A retrospective study of 27 ECMO patients9

67% received solo enteral nutrition.

33% needed supplementary or TPN.

Table 3: Summary points 1. Follow critical care guidelines for nutrition support.

2. Initiate enteral nutrition and build up to target as tolerated.

3. Moderate provision of energy and protein depending on phase of care.

4. Close monitoring of biochemistry, medications, gastrointestinal function and clinical plan.

5. Supplement parenteral nutrition if needed.

patients receiving MV who had higher feeding infusion rates (>50ml/h) had diarrhoea, and for a longer duration.12 It has been reported that the motility of the upper gastrointestinal tract in patients receiving MV is severely impaired; contractile activity is completely lost in the stomach and diminished to a lesser degree in the duodenum.13 Furthermore, the safety of enteral feeding in severe respiratory failure patients, in particular those on ECMO, has been questioned.5 There is an increasing availability of different enteral formulas, differing in their protein, fibre and fat content, such as elemental, monomeric or polymeric. As with any feed intolerance, different feed formulations should be tried alongside medication optimisation and then, if needed, consideration of parenteral nutrition.

Significant underfeeding in critically ill patients in the ICU setting is reported, with patients receiving 52-76% of their daily dietary target, mainly due to gastrointestinal intolerance and elective withholding of feedings for procedures.3,4 An observational study looking at interruptions in enteral nutrition delivery and its impact on surgical patients, found that 26% of interruptions were deemed avoidable and underfeeding was associated with a longer length of stay.17 The critically ill state requiring additional ECMO support, together with underfeeding, can lead to malnutrition and significant muscle weakness. Survivors of critical illness experience significant skeletal muscle weakness and physical disability, which can persist for at least five years.18,19

FEED ADEQUACY

CONCLUSION

The majority of published ECMO studies look at nutrition provision and adequacy. A study of 48 ECMO patients15 found that: â&#x20AC;˘ 18% of nutritional requirements delivered during the first two days of admission increased to 30% when averaged over the first three days; â&#x20AC;˘ 55% of their nutritional target was achieved, which increased to 71% after the patients came off ECMO; â&#x20AC;˘ survival outcome was not associated with nutrition adequacy.

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In summary, a detailed thorough assessment and ongoing regular close monitoring is integral to nutrition support for ECMO patients, as it is for all critical care patients. ECMO is another form of mechanical support for patients and, therefore, it adds to nutritional demands and has a potential for complications. Open communication and close working with the multidisciplinary team is essential to optimise nutritional adequacy and therefore minimise malnutrition and its asociated short- and longterm complications.

FOOD & DRINK

Claire Chaudhry Community NHS Dietitian/ Freelance Dietitian, BCUHB (NHS) and Private

In Claire’s 15 years of experience, she has worked in acute and community NHS settings. Claire has taught nutrition topics at universities and colleges and regularly provides talks to groups, NHS and private. www.dietitian claire.com REFERENCES For full article references please CLICK HERE . . .

ENTOMOPHAGY: THE BENEFITS OF INSECTS IN NUTRITION Entomophagy is the term used for eating insects.

Over 2,000 species of insects are consumed by humans worldwide, mainly in tropical regions. The insect’s eggs, larvae, pupae, as well as the body have been eaten by humans from prehistoric times to the present day.

The most popular insects consumed by humans around the world include beetles at 31%, caterpillars at 18%, wasps, bees and ants at 15%, crickets, grasshoppers and locusts combined make up 13%, true bugs make up 11% and termites, dragonflies and others make up the remaining 12%.1 Entomophagy has been presented to the UK public with programmes like Back in Time for Dinner (2015) and Doctor in the House (2016). These popular TV series featured episodes presenting insects as a food source with mixed opinions. Who can forget anxious celebrities watched by millions in I’m a Celebrity Get Me Out of Here!, participating in bush tucker trials eating insects as part of a punishing task!

WE ALREADY CONSUME INSECTS AND INSECT BY-PRODUCTS

Honey is consumed all around the world and is a by-product of bees that chew the pollen collected from flowers and regurgitate this as honey to feed their young. Cochineal, a red food colouring, is made from crushed scale insects and has been used for many years in food products. Cochineal is found in red cup cakes, pastries, yoghurts, juices and sausages. According to European food law, there is no published list of ‘tolerant’ levels of insect bodies/matter permitted in food. Food businesses are expected to meet ‘Article 14’ of Regulation (EC) 178/2002.2 Despite the regulations, insects do occasionally end up in our

food, e.g. on a leaf of your organic lettuce, or perhaps in a box of cereal.

WHAT ARE THE ADVANTAGES OF EATING INSECTS?

A sustainable food source for the planet With a growing global concern over the increasing population throughout the world and the unsustainable practices used for modern factory farming of animals, the future could be food shortages globally. These very real reasons enable the growing popularity of eating insects, which may prove to be a more sustainable dietary change and or dietary addition.

Insects are extremely plentiful and have a large biodiversity (variety) and are found in nearly all environments.

Insects have a high feed conversion efficiency, which is the capacity to convert feed mass into increased body mass, represented as kg of feed per kg of weight gain. (Crickets need 2kg of feed per 1kg of body weight; cattle require 12kg to produce the same amount of weight gain.)

Insect farming requires less water in the farming of other animals, e.g. cattle, chickens and pigs. Insects also emit less greenhouse gases which are harmful to the environment, compared with cattle, www.NHDmag.com February 2018 - Issue 131

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FOOD & DRINK chicken and pigs. They also have fewer welfare issues (although how insects experience pain is still unknown by entomologists). They also pose a low risk of transmitting zoonotic infections.

Insect rearing or farming is inexpensive, making it a useful livelihood in the poorest sections of the world, also, it does not require the clearing of land to expand production. Manual collection of wild insects could potentially save crops by increasing production and reduce the need for pesticides.1,3 PROTEIN CONTENT OF INSECTS

“Many edible insects provide satisfactory amounts of energy and protein for human consumption.”4 The nutritional values of edible insects are highly variable because of the huge diversity of species. Even within the same group of edible insect species, values differ depending on the stage or lifecycle of the insect, their habitat, temperature and their diet. Like with most food, preparation and processing methods (e.g. drying, boiling or frying) before consumption also influence the nutritional composition.

Cricket flour The history of dietary patterns change, one example is the accept ance of raw fish as sushi in the UK; 40 years ago this would have been unthinkable.

Thus, cricket flour or cricket powder seems a more visually acceptable introduction to entomophagy. In fact, there are a number of products sold in the UK and other countries already, e.g. United States of America and Canada use crickets for flour/powder, flavoured energy bars and pasta.

The cricket flour available to purchase in the UK is made from either two species of crickets: the house cricket Acheta domesticus (AD) and the Thailand native cricket, also known as the Mediterranean field cricket Gryllas bimaculatus.

Manufacturers report that the insects come from farms either in the Netherlands or Thailand. In order to process 100gm of cricket flour/cricket 36

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powder an average of 1,000-1,100 crickets are required and cricket flour/powder cost ranges between £5 and £10 per 100gm.

Four brands of cricket flour’s nutritional composition were compared: ‘Cornish Edible Insects’, ‘Eat Grub’, ‘Crunchy critters’ and ‘Nutribug’ (see Table 1). Energy per 100gm of cricket flour/powder was an average of 475 calories. Protein content in cricket flour/powder was very high with an average of 64gm protein per 100gm. Rumpold and Schluter found that 100gm crickets AD (based on dry matter) farmed in America contained between 55-70gm of protein (cricket flour/powder is a high calorie and high protein food4).

Hazardous chemicals comparable with commonly protein rich foods An evaluation of the literature looked at the prevalence of hazardous chemicals, e.g. PCBs, DDT (a pesticide) and metals found in European Union (EU) farmed crickets AD. The study concluded that levels of several hazardous chemicals were relatively low in farmed EU crickets and that they were similar or even lower than those measured in other commonly eaten foods such as meat, fish and eggs.5 WHAT ARE THE BARRIERS TO EATING INSECTS IN THE UK?

Consumer acceptance There is a limited amount of data on consumer perception and acceptance of eating insects, particular in the UK. In an area of Laos, South East Asia, a national survey looking at the prevalence of insect consumption surveyed over 1,059 adults. The results found that 96% consumed insects and entomophagy was widely accepted in this part of the world.6 Nearer to home, a small study conducted on Italian consumers showed that negative comments from family members and friends seemed to underline the importance of others’ opinions (especially a negative attitude) as a strong barrier against entomophagy.7 2015 saw the launch of ‘Grub Kitchen’, the first insect restaurant in Wales based in St David’s, Pembrokeshire.8 Grub Kitchen has been promoting entomophagy as an alternative protein source amongst school children in

Table 1: Nutritional composition of four cricket flour/powder brands per 100gm Nutrients per 100gm cricket flour/powder

Cornish Edible Insects AD (label)

Eat Grub (species not on label)

Crunchy Critters AD (website)

Nutribug AD (website)

Calories (Kcal)

472

501

518

457

Protein (gm)

58.5

61.8

56.8

67.8

Carbohydrate (gm)

8.4

8.5

5.5

5.5

4

0.5

0.5

2.8

Of which is sugar (gm) Total fat (gm)

Not listed

24

29.3

18.2

SFA (gm)

8.48

8.48

10.5

5.6

MUFA (gm)

5.14

5.14

7.9

Not listed

PUFA (gm)

9.09

9.09

9.4

Not listed

Not listed

Not listed

0.29

0.14

Trans fat (gm) Fibre (gm)

6

6

2.3

<0.5

Vitamin B2 (mg)

Not listed

Not listed

Not listed

3.20

Vitamin B12 (mg)

Not listed

0.024 (24mcg)

Not listed

Not listed

1.1

0.11

Not listed

125

Calcium (mg) Iron (mg) Phosphorus (mg) Potassium (mg) Salt (gm)

0.025

2.5

5.04

5.04

Not listed

705

Not listed

Not listed

11

1.1

Not listed

Not listed

Not listed (sodium 3.1mg)

Not listed (sodium 0.31mg)

0.6

Not listed

London. Food cooked by Andy Holcroft, head chef, includes black ant and cheese pate, alongside cricket and cauliflower bhaji. Reported comments from the school children included “delicious” and “disgusting”.9 Allergic reactions Studies looking at particular allergens causing allergic reactions in humans were found in insects. These allergens are also present in other animals that are part of the food chain including crustaceans, e.g. crab, lobster, prawn and shrimp. The same allergens have also been detected in dust mites and nematodes, e.g. worms.10 These allergens are not fully understood and for safety reasons recommendations have been made that any food label derived from insects now has to state allergy awareness.11 Dr Isabel Skypala, Allergy Dietitian reported in June 2017 in The Telegraph that allergies in adults have increased as a result of a rise in cochineal consumption

from the trend of red cupcakes.12 There has also been an increase in the number of histamine poisoning and/or scombroid poisoning outbreaks occurring from consuming insects.

These conditions can result in flushing and urticarial rashes of the skin, headache, nausea, diarrohea and vomiting. In worst cases, patients develop respiratory and breathing problems.13 Lack of clear policy for the UK European legislation via regulation EC 258/97 (repealed from January 2018 by regulation EU 2015/2283) states that all insect-based products (not only parts of insects or extracts, but whole insects and their preparation) belong to one of the categories of ‘Novel Food’. In the UK, the Food Standards Agency (FSA) classifies cricket flour/powder as a Novel Food and from June 2017 requires a Novel Food safety assessment from all suppliers of insects used for human consumption.14 www.NHDmag.com February 2018 - Issue 131

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FOOD & DRINK Microbiological contamination A study pyrosequencing microbial counts of Gryllus bimaculatus cricket flour/powder found that it contained high amounts of Enterobacteriaceae which are associated with soil contamination, human and animal faeces and high amounts of Clostridium perfringens which in large amounts can cause food poisoning in humans.

There was also presence of mould spores and opportunistic pathogens, e.g. Pseudomonadaceae and Lactococcus garvieae.15 Another study looking at four different heat treatments for Gryllus bimaculatus whole crickets found that the microbial quantity depended on the heat treatment and total bacteria counts were generally high in the samples, concluding that there is a need to establish effective species specific heat/drying procedures to ensure food safety and also to maintain nutritional quality.16 Moulds such as aflatoxin, which in high amounts can cause food poisoning,4 have been detected in foods such as peanuts, corn and edible insects. The control of microbes and detection of mould is best achieved by measures designed to prevent the contamination during storage, or detection and/or removal of contaminated material from the food supply chain.

Vitamins and minerals: levels inconsistent and not all are listed The cricket flour labelling regarding vitamin and mineral content has been inconsistent (see Table 1). ‘Eat Grub’ stated on the label that the cricket flour per 100gm contained 0.024mg (24mcg) of vitamin B12. This level of vitamin is high, containing four times the amount that is in 100gm of wild baked salmon.17 However, the other flours failed to list this vitamin. Riboflavin B2 was listed as 3.2mg in ‘Nutribug’ which is high; however, the other companies did not list B2 levels.

Calcium was listed in three of the flours, but was varied from the lowest of 0.11mg to 1.1mg to 125mg. Arnold Van Huis stated that, ‘Most species of insects contain little calcium because insects as invertebrates do not have a mineralised skeleton’.1 Potassium amounts were quoted in two of the flours; one contained 11mg, the other 1.1mg, differing greatly. Only one 38

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cricket flour quoted the inclusion of phosphorus and provided 705mg in 100gm of ‘Eat Grub’ cricket flour, which is high and comparable to drinking 750ml of semi-skimmed milk. Despite sodium no longer being permitted on a UK food label, sodium mg was listed on two of the flours and again were at different levels.

There are a few studies looking at the iron content of crickets,1,18 Rumpold and Schluter found that iron within Acheta domesticus crickets (dry matter per 100gm) ranged from adult crickets containing 6.27mg to juvenile crickets being highest at 19.68mg.4 Iron amounts also differed in the flours, ranging from 0.025mg (25mcg) to 5mg. In fact, due to the wide differences of iron content between ‘Cornish Edible Insects’ and ‘Eat Grub’, the companies were contacted and advised to double check their mg and gm.

Volume of 100gm insects eaten Eating 100gm of insects will be substantially more in volume than eating 100gm of meat if using cricket flour or cricket powder in baking muffins or biscuits. According to Fred McVittie from ‘Cornish Edible Insects’, due to the high amount of protein in the flour, only 10% of the recommended flour amount in gm is needed. So, for the double chocolate chip and ‘cricket’ muffin recipe, which requires 375gm of self-raising flour, 37gm of which is substituted by cricket flour to make 12 muffins.

Therefore, in order to consume 100gm of cricket flour, 33 muffins would need to be eaten!

There are other nutritionally comparable foods In comparison, there are other rich protein foods that can be consumed which match the macronutrient profile of cricket flour. A meat alternative, (albeit an unusual combination), consists of 2tbls of red cooked lentils, one cooked leg of chicken and one small fillet steak grilled (110gm), providing 446kcals and 62gm protein. A more plant-based meal and a more sustainable dietary option is three portions (340gm) of cooked mycoprotein pieces (e.g.

Quorn) and six Brazil nuts, providing 384kcals and 50gm protein. Unsurprisingly, the vitamin and mineral content of these two suggestions are, of course, far greater than the cricket flour,

and the plant-based suggestion also provides more fibre.

Cricket flour/powder is a high protein

high calorie food product, which has evidence of

Multiple uses of insects is limited Insects do not provide multiple uses like other animals that are farmed, e.g. dairy products, gelatine, wool, suede, leather and fur.

benefits for our future environment when compared with other farmed animals in the current food chain.

FURTHER RESEARCH IS NEEDED

Further research is required on the processes involved in the large scale production of insect farms, e.g. insect’s diet, hygiene practices of processing, storage, handling and transport of the insects alive and/or dead. This will, therefore, lead to the development of a UK policy to protect consumers.

All labelling in the UK has to comply with EU labelling policy regulation 1169/2011, which is the provision of food information to consumers regarding front-of-pack labelling: • Correct nutritional information for macronutrients per 100gm, also using the UK traffic light labelling system, e.g. RIs comparing total fat, saturated fat, sugar and salt.

• Information on vitamins and minerals is not mandatory, but would be beneficial if a food product is high in certain nutrients.

• The labelling of sodium is not permitted, it has to be salt (sodium chloride) expressed in grams.

• All ingredients must be listed in descending order of weight if added to the insects.

Ingredients such as vegetable oils, must also have the type of oil listed as well, e.g. palm oil and sunflower oil. If there is any hydrogenated oil on the label, it must state if it is fully hydrogenated or partially hydrogenated.

• Where the allergen is not obvious from the name in the ingredient, there should be a clear reference to the name of the allergen next to the ingredient. Food business can

choose how to highlight the allergen in either bold, italics or underlined fonts. An allergy advice statement at the bottom of the label may also be used, e.g. ‘Allergy advice: for allergens see ingredients in bold.’

It is recommended that insects and insect-based product are heated by the consumer before consumption. Boiling/oven baked/ frying the product will help to reduce the bacterial load, in particular for immunocompromised individuals.

The vitamin and mineral composition of cricket flour/powder needs further clarification and uniformity. Also, further studies are required regarding the bioavailability of minerals in humans from entomophagy, e.g. iron absorption.

CONCLUSION

Cricket flour/powder is a high protein high calorie food product, which has evidence of benefits for our future environment when compared with other farmed animals in the current food chain. However, further research is required, in particular on vitamin and mineral composition and food safety, before dietitians can ‘chirp’ about the nutritional benefits of cricket flour/powder.

Acknowledgement With thanks to the companies who provided me with information on cricket flour/powder and Fred Mcvittie from Cornish Edible Insects who provided me with his time, advice on cooking insects and a free sample of cricket flour/powder. www.NHDmag.com February 2018 - Issue 131

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NHD and British Lion eggs Competition Write an article for the chance to win £250 in shopping vouchers!

Network Health Digest (NHD) and British Lion eggs, would like your original research reviews on the role of eggs in the diet. We are looking for fully referenced articles discussing the role and implications of eggs as a nutrient provider to different population groups and/or life stages. Suggested topics include the role of eggs in the context of: sport and fitness, pregnancy and early life, satiety and healthy ageing.

The best two articles will be published in NHD later this year and the two winning authors will each win shopping vouchers worth £250.

Deadline for submission: Friday 6 April 2018.

All entrants will be judged by NHD Editor and Registered Dietitian Emma Coates, along with Dietitian and Health Writer, Dr Carrie Ruxton.

NETWORK HEALTH DIGEST

Please email info@networkhealthgroup.co.uk for a ‘Contributor template’ and further guidance on submissions.

WEIGHT MANAGEMENT

TERMS OF BELONGING: WORDS, WEIGHT AND ETHICAL AUTONOMY Lucy Aphramor PhD RD Dietitian Self-Employed Lucy Aphramor developed Well Now, an approach to nutrition that teaches compassion, fosters self-care and advances social justice.

She is an awardwinning dietitian, and a spoken word poet.

In this article, I explore how the language we use to describe body size impacts our practice and shapes people’s lives. I unpick some of the assumptions behind the terms we use and finish with a vision of difference.

The article is influenced by my practice as a UK dietitian working to promote body respect and health justice through Well Now,1 a practice that in turn is shaped by personal experience.

As nutrition practitioners, we take care with the words we use to describe ourselves. Our professional organisations are strongly invested in delineating the terms nutritionist, dietitian and nutritional therapist because words impact identity and status.

HOW LANGUAGE FRAMES THE BODY AND POSSIBILITIES

REFERENCES For full article references please CLICK HERE . . .

As a dietetic student 20 years ago, I wasn’t aware that I was being taught to look at fatness and thinness through the particular lens of reductionist science.

I mean, I knew this was science, but I didn’t know that there was more than one way to approach science. And so I thought that what I was taught to think about body size was the best, indeed the only, credible way to think.

It seemed self-evident that fatness was always a public and personal health issue in need of intervention. It never occurred to me that there could be alternative ways of thinking about fatness that did not centre on health, or calories, or fixing. I never questioned where all the fat student dietitians were, I mean, obviously there weren’t any, right?

I took it for granted that professional guidelines were based on an unbiased analysis of the ‘best available evidence’, though the term itself was yet to enter dietetic rhetoric. It never occurred to me to ask about adverse effect, or social determinants of health,

or fat rights. I have a mix of emotions when I remember casually ridiculing fat people in a department sketch: shame for diminishing anyone, and especially as a thin person shaming fat folk; outrage and bewilderment that my education supported this world view and I was unable to see how wrong this was myself; compassion when I reflect on some of the things that blocked my view; an enduring passion for change.

Within this framework I had no cause to question the fact that the language used to talk about fat people and larger bodies was one of pathology - the ‘o’ words. Neither did I think to question the associated use of BMI categories as a reliable way of assessing and intervening in individual illness or health. I mean, why would I? As you’ll have guessed, I have since thought lots about how we use language in dietetics. And I have also come to realise that reliance on BMI as a pivotal health measure indicates allegiance to a particular stance, or ideological position. That it is not, after all, an inevitable hard fact, it’s one choice among others.

Why does any of this matter? I’ll focus on just three areas. First, what are we saying when we use the ‘o’ words: obesity, obese and overweight?

Second, what BMI implies about lifestyle, social determinants and health. And third, what are we saying when we won’t say ‘fat’? www.NHDmag.com February 2018 - Issue 131

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YOUR ESSENTIAL RESOURCE

WEIGHT MANAGEMENT USING THE ‘O’ WORDS: THE FAT BODY AS A DIAGNOSIS

The term obgobbing2 (Box 1) was coined to name the practise in which fat people’s bodies are described using words that foster oppression - the ‘o’ words again. Naming obgobbing as a phenomenon problematises something that might otherwise pass unnoticed. It serves to draw attention to norms that harm and to alternatives. It is a strategy that helps us envision a different world.

What’s wrong with the ‘o’ words? A starting point is that they diagnose fat people as always and essentially unhealthy and wrong-bodied.

So obgobbing irrevocably links a person’s physicality with disease. Of course, people of different weights and heights may or may not be ill, that’s not the point. The point is that when we use the ‘o’ words we create a world in which there is nowhere a fat person can exist outside of medical reference. And where they are always deemed to be flawed and at fault.

Obgobbing is oppressive because it perpetuates myths and stereotypes concerning health, weight and social justice that impede justice.

We know that there are links between height and poor health and yet dietetics has ways of referring to people’s stature outside of medical reference. Of course, a key reason we do not routinely flag up height-health links hinges on the fact that our height is not seen as a matter of choice, whereas our weight is. Inherent in the diagnosis “too fat” is the assumption that everyone can and should be thin. So, when we use the ‘o’ words we make fat people culpable: guilty of not being thin, guilty for any health problems they may have. Moreover, in this framing, BMI is pivotal to health and social factors barely register.

PREJUDICE-BASED MEDICINE?

The ‘o’ words construct categories that ratify a model of health in which BMI functions as a reliable indicator of personal health, and is deemed largely under personal control.

The BMI model asserts that trying to lose weight does more good than harm. But does it? I know it can seem ridiculous to query this cornerstone belief, but if you’re never searched the primary data, bear with me. I researched

Box 1: Obgobbing2 A phenomenon in which fat people’s bodies are described using words that foster oppression. The words may be used thoughtlessly, inadvertently or intentionally. Paradoxically, obgobbing is strongly prevalent in healthcare where it buttresses a neoliberal ideology. Obgobbing enacts power relations that strengthen existing hierarchies in knowledge creation and so it is helpful to those whose interests are best served by maintaining medical and academic norms. It serves to repress marginalised voices and cultivates systems of thoughts and practice that deny people their agency and dignity. It is, therefore, relevant to human rights, and is a health hazard.

the evidence when I realised the shortcomings of my ‘eat less, move more’ advice. Ideally, for evidence-based medicine (EBM), we need to find a systematic review of randomised controlled trials of intentional weight correction with longterm results. Fortunately, such a review does exist, with results at two years.3 This shows that efforts to lose weight did more harm than good. It is an understatement to say that this finding has huge implications. Bluntly put: the best available evidence within the parameters of EBM shatters any claim that advice on weight correction is consistent with EBM. When we use the ‘o’ words we reinforce conventional beliefs about the evidence base, beliefs which are erroneous and harmful. To reiterate, in the review mentioned above - a gold standard of EBM - authors conclude the following: ‘The benefits of dieting are simply too small and the potential harms of dieting are too large for it to be recommended as a safe and effective treatment . . .’8 You can check out the quality of the review by accessing it online here: www.janetto.bol. ucla. edu/index_files/Mannetal2007AP.pdf. 8 What does this mean for your practice? For the profession?

When we discover something previously unimagined like this, we find ourselves at a crossroads. We can close our eyes to the new perspective and resume business as usual, or we can exercise our ethical autonomy (a concept from the educator Parker Palmer) and act on the new knowledge. www.NHDmag.com February 2018 - Issue 131

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WEIGHT MANAGEMENT WHAT’S MISSING IN BMI-BASED HEALTHCARE?

There are far-reaching ramifications in learning that advocating weight loss is harmful. The problem is not just that “diets don’t work” or that dieting is linked with individual health detriment, shocking as this may be, but, that BMI-based health encapsulates the belief that focusing on lifestyle change will significantly enhance population health. This is a fallacy: the lifestyle change approach conceals the fact that non-lifestyle factors4 (so-called ecosocial determinants) overwhelmingly determine population health. This distortion is a topic in itself, for another time.

WHAT ARE WE SAYING WHEN WE DON’T SAY ‘FAT’

It is easy to find work by fat activists, allies and academics explaining why they reclaim fat.5 This begs the question “what are we saying when we won’t say fat?” Whether we intend it or not, we are saying that the voices and agency of civil rights groups don’t count. We enact oppressive power dynamics as we disdain the stance of a marginalised group. This is incompatible with professional integrity, with profound ethical implications.

On a personal level, if you feel squeamish about saying fat, why is this? What does this say about fat prejudice, about thin privilege, about your own body confidence, your own body shame? Reflecting compassionately on our intellectual and visceral responses can be valuable work.

CATALYSING CHANGE

Fat bias is rife. Thin privilege reigns. Institutional sizism6 and the related belief in ‘lifestyle health’ shapes dietetics, counselling and public health.

How does our language impact this? How can we use our power responsibly? Change starts by questioning the habitual. In my experience, dropping the ‘o’ words for descriptive terms like fat, or larger bodies, has an immediate disruptive effect on routine professional narratives. This interruption opens space for a different conversation on fat, one that engages with language and values and ethics. One that contains within it the seeds of transformation, where we educate ourselves as allies in the struggle for weight-justice.

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So, it is of pressing importance that we figure out how to talk newly about body size with clients of any weight so that we challenge fat bias and foster body respect for all. At the same time, we need to ensure that we remain sensitive to people’s personal histories of fat shaming, and mindful of the ways our own embodiment, and our learning and unlearning, influence therapeutic dynamics.

Grappling with new insights has personal consequences too. Alongside growth in understanding there can be grief, relief, confusion, ambivalence, guilt, and more. Both emotional and intellectual labour are called for.

Further still, it may feel frightening to start the conversation with colleagues. The moment we consider speaking up may be the moment we first become aware of the privileges we hold from adopting normative views. How do you think your questions will be received by colleagues?

What does this tell you? Raising the issue of language and justice prompts us to consider what else is at stake as we bring into focus the question ‘How does saying fat and dropping the ‘o’ words impact professional legitimacy?’

ADVANCED COMPETENCIES

The European Federation of the Associations of Dietitians is currently revising advanced competencies to support an ethos of deep engagement. We are enjoined to ensure that our work meets core values of health promotion, including social justice, equity and participation, with competencies that reflect the work needed rather than reinforce the practices that already exist.7 To this end, it is necessary to continually reflect on language, but this will not be enough.

We also need to become aware of the deep roots of sizism and work to dismantle them. If these views are new to you, why is that? Does it matter that you weren’t introduced to them in training? If you think these perspectives are relevant to practice, how can you continue the learning? Why does dietetics disregard activist voices?

BODY RESPECT: THE FUTURE OF FAT

I reject the ‘o’ words because I am not working for a world without fat people. I use fat and

other descriptive terms, because I am working for a world that is weight diverse, where nobody is starved of food, company or dignity - or equitable healthcare. To get there, we need to draw on a knowledge base that extends beyond reductionist science. Along the way, dietetics would become more representative of the population we serve, welcoming students of all sizes and identities.

Our work would be theorised within a framework that is socially aware, so that we feel confident in promoting body respect, linking self-care, structural change and sustainability.

We commit to supporting each other as we grapple with new ideas, not getting stuck in caretaking our professional fragility, or stopping at critical thinking, but as an ongoing and integral part of advancing social justice and wellbeing.

People of all identities, including fat folk, belong here now, and in the future. In a fair, health-promoting world, nutrition practice will communicate this.

Box 2: Excerpt from ‘Planning for Fairness’ by Dietitians for Social Justice • • •

•

•

• •

Are images of this group respectful and inclusive?

Is the language used to describe this group respectful and inclusive?

How do you engage with people in the group, including activist voices, to understand need and experiences in relation to health services?

Is this group appropriately represented in all levels and practice areas within the dietetics profession? If not, does anything need to change? What are the short-term and longterm goals? How can this change process be started? How are we learning from students’ experiences?

Does the research include the voices of the people from the group, critical perspectives and rights-based work?

How does the proposed treatment and framing enhance health equity?

How does the proposed treatment and framing detract from health equity?

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F2F

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

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Ursula meets amazing people who influence nutrition policies and practices in the UK. PAMELA MASON Pharmacist Nutritionist Environmental author/champion

More than a year ago, Pamela was the first person I asked when planning my series of interview columns. This January I got lucky-lucky-lucky: a chance to spend a few hours talking to someone who I have always looked up to from afar.

Thank goodness (in hindsight) that Pamela’s A-Level choices, Physics with forced partner subject Maths, and Chemistry, shut the door to vague hopes of becoming a medical doctor (because of the lack of Biology.) Not being a doctor gave her the clear path to become Britain’s only double-barrelled nutrition and pharmacy expert. She chose to study pharmacy at the University of Manchester and her ability to rote-learn allowed her to glide smoothly through exams and projects. Her early career was within the comfortable confines of retail community pharmacy.

But her young husband had had enough of lawyering, so they took a big jump professionally and financially and bought their own pharmacy in a small town in Wales. Pamela enjoyed the privilege of deep insights into the health of the local community, but became increasingly anxious about her role of offering ‘carpentry advice about stable doors’ when horses had bolted. “There was a child requiring a fifth course of antibiotics one winter. I was then shocked to discover that the child lived almost entirely on potato crisps,” said Pamela.

She became more observant of lifestyle effects on health and mild interest was set alight when an American woman told her about her passion for nutrition author

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Adelle Davies. Reading Let’s Eat Right To Keep Fit was the book that first opened Pamela’s eyes to the many influences of food choice on health. This revelation from Pamela astonished me. It was the same book that started my own interest in nutrition science: we agreed that Adelle Davies would be viewed as cranky by most dietitians, but we both owed Adelle recognition and respect as the fire-starter of our professional enthusiasms.

Pamela’s husband decided to move to London to develop his career in the Church and so the pharmacy in Wales was sold. Queen Elizabeth College, now King’s College, offered a one-year Master’s degree in Nutrition Science and Pamela signed up. Professors Naismith/ Sanders/Judd inspired her to continue with PhD studies and five years later, the demonstration that there is some adaption in rates of mineral absorption with high-fibre diets, gave Pamela her doctorate in nutrition.

In the early 1990s, Pamela juggled two jobs. One was with the Royal Pharmaceutical Society doing edits and updates to the British National Formulary (BNF). The other was with the National Pharmaceutical Association producing distance learning programmes for pharmacy assistants. “I was really lucky to have found such intellectually interesting jobs,” said Pamela.

Standing by the coffee machine, Pamela mentioned to a colleague, who happened to be the editor of Pharmaceutical Journal, that she had been able to visit a pharmacy during

a holiday in newly unshackled and politically liberated Romania. Of course, he wanted her to write an article on her observations; which would be of huge interest to British pharmacist readers.

And, of course, Pamela was then identified as the expert writer on all matters to do with nutrition.

Because Pamela was uniquely double qualified, demands for her time and attentions grew and she was recognised in particular for her expertise on nutritional supplements.

Her first book provided guidance on nutrition advice in the pharmacy. Her second book, Dietary Supplements, published by Blackwell, was the ultimate reference compendium on nutrition and special ingredient supplements.

It was very popular with pharmacists; perhaps, unfortunately, dietitians were less aware of this publication. Later print updates were produced by the Pharmaceutical Press and this title still keeps Pamela busy, as current quarterly updates are available to online subscribers of Martindale and the BNF. In 1994, Pamela became a freelance consultant. She was a guest lecturer, a contributor to many diverse pharmaceutical and nutrition publications, and an industry advisor. At the time, there was fierce debate in the European Union (EU) on how nutritional supplements should be regulated: the UK had the most liberal approach, contrasting with much tighter supplement dose limits and distribution controls in other EU countries. Industry and government and health professional groups all wanted Pamela’s advice on these complex matters that blended science and policy.

In 2003, it was time to return to Wales. Pamela’s husband was now a vicar and she wanted to support his role in the community. Of course, she made teas and cakes to raise funds and support those needing help and comfort. But it was known that the vicar’s wife was a nutrition expert and Pamela had many opportunities to consider the wider and longer paths to food choices, including many revealing and profound discussions with

local farmers. “It really struck me that foods were much more than just being nutrient containers, and that to help people improve their diets, you really had to delve into the many influences that channel choices. I became very enthused with the whole new area of food policy,” said Pamela.

Reading a few articles was not enough: Pamela always wants to understand topics properly, so she signed up as an age 50+ student, to do an MSc in Food Policy at City University in London, with Professors Tim Lang and Martin Caraher. Her project was on healthy food choices of low-income single mothers in Abergavenny, concluding >possible: yes; probable: no.

There were massive pressures and adjustments to UK and international food supplies as a result of newer awareness of environmental aspects of food production and distribution, and Pamela decided to write a book on this. Initially publishers were lukewarm: did anyone really care? But when Tim Lang agreed to be a co-author, doors opened and contracts were signed. This huge project took four years and Sustainable Diets was published in the spring of 2017 (see book review in NHD issue 126 - July 2017).

It must have been hard to produce such a complicated and information-dense tome, I marvelled. “Err … yes, Ursula,” confirmed Pamela. “Science writing can often be structured and formatted, but writing policy texts can be hard because more malleable information requires constant redrafting,” she explained.

Sustainable Diets is the ultimate review of this ‘smoking hot’ topic of plant-based diet, which puts new light onto the tensions first captured

by Cain (pasture) and Abel (livestock). Pamela hints to me that the book may be on the desks of the CEOs of many large food companies and environmental organisations. Again, Pamela has managed to become the in-demand expert on complex matters blending science and policy.

We part, but I have a neck ache: it is from looking up to her so much. She is not tall, but she will always be the cleverest person in the room.

If you would like to suggest a F2F date

(someone who is a ‘mover and shaker’ in UK nutrition)

for Ursula, please contact: info@networkhealthgroup.co.uk www.NHDmag.com February 2018 - Issue 131

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IN ASSOCIATION WITH THE NSPKU

IMD WATCH

METABOLIC DIETETICS Suzanne Ford NSPKU Dietitian for Adults

IMD watch turns the tables and shines the spotlight on the people who practice Metabolic Dietietics - who, what, where and more importantly why?

Suzanne Ford is a Metabolic Dietitian working with Adults at North Bristol NHS Trust and also for the National Society of Phenylketonuria).

I asked some enthusiastic and committed metabolic dietitians who work in a range of settings, why they chose this career path, how they came to get involved with Metabolics and what their jobs entail. Working with metabolic patients involves manipulation of carbohydrate intake, or fat intake, or

protein intake and sometimes in various contexts of tube feeding, pregnancy, supporting sporty lifestyles, or just getting safely through a day at school.

Often in metabolic disorders there is no other treatment, only diet, so the work is intense and detailed and the responsibility can feel significant.

Figure 1: Metabolic pathway changes in different types of Tyrosinaemia (and also phenylketonuria).

STEVE KITCHEN: TEAM LEAD FOR IMD DIETETICS, BIRMINGHAM WOMEN AND CHILDRENâ&#x20AC;&#x2122;S NHS FOUNDATION TRUST Caseload: Babies and children with all IMD conditions specialising in Glycogen Storage Disease and Tyrosinaemia.

Steve got into Metabolic Dietetics about four years ago - Steve was attracted to the unknown and complex nature of Metabolics and by the passion of the Birmingham IMD team. He had worked in both acute and community work, with complex care, food allergies and home feeding among his caseload. Since starting his metabolic post, Steve has enjoyed a very steep learning curve and is still learning all of the time. In practice, knowledge of biochemical pathways and clinical reasoning are key, whilst being able to tailor feeding plans to individual patients. No one patient is the same - Steve cites the examples of Glycogen Storage Disease â&#x20AC;&#x201C; these are categorised by 14 different types and within those groups a/b/c variants along with phenotypic variation of the patients. Steve says, it requires a lot of patient contact to get some patients to 'stable' and close monitoring is required alongside working within the multidisciplinary team.

Typical day: Clinics, inpatient work, home visits and managing the Metabolic Dietetic team at Birmingham.

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A group of enthusiastic conference goers, many of whom were exhibiting poster abstracts or presenting orally at the International Congress for Inborn Errors of Metabolism, 2017 left-right back row: Ewan Forbes, Sarah Adams, Lesley Robertson, Melanie Hill, Tanya Gill, Joanna Gribben, Orla Purcell, Carolyn Dunlop, Dr Alison Cozens. Front row left-right, Hayley Altenkirch, Suzanne Ford, Alex Pinto and Clare Swzec.

JO GRIBBEN: LEAD PAEDIATRIC METABOLIC DIETITIAN, EVELINA CHILDREN’S HOSPITAL, LONDON

Jo has been at the Evelina Children’s Hospital for 17 years (before that she had a rotational paediatric job at Great Ormond Street). Jo works three days a week managing her team and working clinically with infants and children with a range of metabolic conditions. Jo says she loves her job as every day is different and there is great job satisfaction. She uses her knowledge from university of biochemistry, nutrition and sociology to interpret biochemical pathways and translate complex diets into practical and achievable diet plans. Jo and her team work alongside a dietetic assistant devising pictorial plans to ensure that non- English speaking families, or those who have literacy problems, can comply. She likes to think that her team can teach anybody!

Apart from teaching patients, Jo also enjoys teaching new staff members, dietitians on the BDA Module 4 and visiting dietitians from abroad. There is always more to learn in Metabolic Dietetics and so one of the frustrations is not being able to get everything done. The Evelina has a great multidisciplinary team which includes a team of specialist nurses, psychologists and medics and the adult service is very closely located, so helping patients transitioning seamlessly within the same hospital and trust will have significant advantages (and this is quite unusual in the UK).

SUZANNE FORD DIETITIAN ADVISOR FOR NSPKU - NATIONAL SOCIETY FOR PHENYLKETONURIA Caseload: Potentially 6,000 people in the UK who have Phenylketonuria (PKU).

Nearly 10 years ago, I started work with a caseload of adult metabolic patients at North Bristol NHS Trust, where I still work as a Metabolic Dietitian. Eight years later, I applied for this job and added Freelance Dietitian to my CV by joining the NSPKU. Since then, I’ve learnt much more about the low protein diet, PKU living and the PKU community in the UK. I’ve improved my tweeting skills and event management skills, as well as dietetic knowledge. I have a lot of flexibility in my work - on home working days I can start at 6am, have a two-hour break for errands or keep going till 10pm if I want to. www.NHDmag.com February 2018 - Issue 131

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IMD WATCH Typical day: There isn’t one! I’ve scoured online shopping websites for low exchange foods, I’m arranging for phenylalanine analysis on a range of foods, writing articles for News & Views (the NSPKU magazine), developing Christmas recipes, or highlighting new products. Away from home: I design the programme and menus for the annual NSPKU conference, I’ve helped run a study day with Louise Robertson, (Adult IMD dietitian) and I’ve just run a multidisciplinary meeting on PKU treatment access. The two most surprising events were speaking in the House of Commons at an event for MPs on International PKU Awareness Day and also appearing on the BBC News Channel to explain PKU following a court case about access to a drug treatment for PKU (BH4 known as Kuvan). NSPKU have set up a YouTube channel so both these appearances can be viewed over and over again! I still work in the NHS and this combination provides huge job satisfaction; my patients give me indepth and authentic feedback! (Twitter Fans look for @NSPKU and please do follow).

ANNE DALY: SENIOR METABOLIC PAEDIATRIC DIETITIAN (INCLUDING RESEARCH) Caseload: Older children and teenagers with PKU; babies and children with organic acidaemias

Anne does clinical practice three days a week and research two days a week. The absence of other treatments is very motivating and makes the dietitian’s role indispensable. Patients are the lifeblood and the satisfaction is seeing the impact of your dietetic treatment on their clinical wellbeing. The challenge of the rare conditions is that you are designing the main treatment, the diet therapy and it is very bespoke to every child. The research element is even more challenging and a chaperone or mentor is needed for developing protocols, ethics, statistics - this is usually a team effort. Undertaking research is a privilege as it can fundamentally change practice globally - and results can be seen.

Managing clinical work alongside research is what Anne considers to be a vital combination. Anne’s message to anyone wanting to go into Metabolic Dietetics is that you need to be prepared to give more than 9-to-5, but that it could open many doors in unexpected directions.

ALEX PINTO: METABOLIC RESEARCH DIETITIAN

Alex doesn’t have any direct patient responsibility, however, he has a great knowledge of patients, as he attends many patient events and helps children get to grips with low protein cooking, as well as collecting data for research projects. He loves children, loves helping them at events, helping them test out products new to them and generally interacting with small people. Alex has networked with dietitians throughout the UK and Europe to find out current practices in less welldocumented metabolic disorders and in PKU, the detail of infant feeding practices. Alex has had six papers published already and has presented poster abstracts and oral presentations at national and international conferences. He thinks the way forward for research in Metabolics is through education and closer links with universities - Alex is now underway with his PhD through the University of Plymouth, although he and his research subjects are both based in Birmingham.

Typical day: There isn’t one - a day could involve party planning for one of the many metabolic children’s parties that Alex has helped with; ethics documents preparation; data collection; statistical analysis work, writing and more writing and then practicing those research presentations till they are 100% perfect.

RACHEL WILSON, CLINICAL SCIENCE DIETITIAN, VITAFLO

Rachel has worked for Vitaflo for just one year. Rachel first specialised in stroke then moved into Metabolics in 2013, working at UCLH. Rachel has never regretted the move to adult Metabolics - it’s varied, and diet plays a big role in a patient’s life-long management. Now, working in industry, she feels she can use her dietetic skills, but has less of the emotional stress which can come with looking after very ill individuals. Rachel enjoys seeing patients at Vitaflo events and has many projects that are informed by patients and their dietitians. Rachel is working on research projects and educational support with a special interest in Maternal Dietetics.

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Significant plus points: Having a wider impact on metabolic patients through supporting metabolic dietitians delivering their clinical service. Health service colleagues are also quite envious of Rachel’s ergonomic desk and she has business cards!

CHARLOTTE ELLERTON, SPECIALIST METABOLIC DIETITIAN, CHARLES DENT UNIT, NATIONAL HOSPITAL FOR NEUROLOGY & NEUROSURGERY, LONDON Caseload: Charles Dent Unit sees over 1,000 dietary-treated metabolic patients Charlotte’s focus is on Maternal Dietetics and she is involved in clinical research.

Charlotte works in one of the biggest metabolic centres for adults in the UK and Europe and she is one of the lead dietitians in the unit. Charlotte says that what she does every day is the essence of her interpretation of Dietetics: translating science into food.

Her first job was a general Band 5 post supporting adults in a district general hospital before moving into the completely new field of Metabolics. She then completed a paediatric rotation in different specialties which taught her so much, and also helped confirm her love for metabolic work. The role can be emotionally challenging, particularly in the care of individuals with complex conditions who she gets to know very well (along with their families) as they are usually patients ‘for life’ as they are rarely discharged. Sadly, sometimes during pregnancy, the risks to mum and baby can be high, and there are some tough days. The dedication of these women to follow extremely restrictive diets to protect their unborn baby is exceptional and humbling. The highs in Charlotte’s work are being able to help support women with the dietetic aspect of their pregnancies and seeing the joy that the babies bring to families - particularly in conditions not renowned for successful pregnancy outcomes.

As you can see, metabolic dietitians are passionate about their work and our caseloads are growing!

If you see jobs in Metabolics advertised in the future, please remember these first-hand accounts and know that this is one of the most fascinating and rewarding branches of Clinical Dietetics you could choose. I hope you enjoyed reading about these dietitians. If you want to know more about the work of the BIMDG and NSPKU then go to www.bimdg.org.uk and www.nspku.org

dieteticJOBS.co.uk • Quarter page to full page • Premier & Universal placement listings • NHD website, NH-eNews and Network Health Digest placements

To place an ad or discuss your requirements please call (local rate)

01342 824073 www.NHDmag.com February 2018 - Issue 131

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FREELANCE PRACTICE

GOING FREELANCE: FINDING YOUR NICHE Priya Tew Freelance Dietitian and Specialist in Eating Disorders

The freelance world is so exciting, I completely love it and it terrifies me all at once. There are many areas you could work in. So much scope and so many people to reach. It can seem a bit daunting initially, so how do you reach out and find work?

Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, consultancy for food companies, eating disorder support, IBS and Chronic Fatigue. She works with NHS services, The Priory Hospital group and private clinics as well as providing Skype support to clients nationwide.

My top tip would be to take time to not find work. I try to do this as an exercise at the start of each year. Spend some time thinking through what you want to do, what are your dreams. Here are some good questions to help you get your focus: • Who inspires you in the dietetic field?

• Who inspires you out of the realm of Dietetics?

• Where do you see the profession going?

• Why are you going freelance?

• What are your wishes?

REFERENCES For full article references please CLICK HERE . . .

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Write out that wish list and then you can start building your brand.

This is exactly what I didn’t do! I started out my freelance career with no proper business plan or idea of where I was heading. I had no NHS experience and no specialist area, just passion and guts. I chose the freelance path as there were not enough jobs in my area and being married and owning a house, I couldn’t move out of my area for a job.

I was lucky enough to have the luxury of time to build both my reputation and business up. I connected with other kind dietitians who mentored me, gave me some work, which helped me cut my teeth, I am so grateful to them and still work with them on things now.

When I discovered that there weren’t hundreds of people knocking on my door for consultations, I created my own tasks instead. I wrote my own healthy cooking course, applied for funding from grants and ran my courses

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very successfully for years. I also did everything and anything that came my way and had a lot of fun with it.

All this helped, but I don’t think it was the best way to build my brand.

What it did show me was the type of work I enjoyed and was good at. I did a lot of work for free, or for too little pay, which isn’t advisable! If I was starting out as a freelancer now, I would take time to find my niche first.

SOCIAL MEDIA

That was before social media was so prevalent. Now, social media means you can build your brand before even starting to do any work. You can build your credibility by sharing articles, writing blogs, connecting and chatting to others in the field you want to specialise in. Knowing your niche means that you can design your whole business persona around what you do.

Your website, social media and marketing can all be tailored to reach the right demographic. It also gives you the chance to refer to others who specialise in different areas and be specific about what work you take on. I love being able to refer onto other dietitians and make sure people are getting access to the right help.

My niches now are eating disorders, media and social media work. Even Pilates creeps in! (Yes, I know it's not Dietetics, but I run a Pilates studio too). So, my blog focuses on eating disorder advice, family recipes and my social media combines Dietetics and Pilates. My website has all my media

Now, social media means you can build your brand before even starting to do any work. You can build your credibility by sharing articles, writing blogs, connecting and chatting to others in the field you want to specialise in. work showcased. I love variety in what I do, so I also take on work with brands and am open to all kinds of work, even though my clinical workload is very niche. I literally only see patients with some form of disordered eating/ eating disorder, IBS, chronic fatigue and some weaning/pregnancy clients. Everything else I refer onto others.

WHAT ARE YOU WORTH?

Charge what you are worth. Of course, if you are a specialist and are advertising that, then you need to be charging the right amount to reflect your expertise. Oh my, this is something I personally find hard. As dietitians working in the NHS, it is all about keeping the costs down and I don’t think we learn to value our worth.

Your years of study, your ongoing learning, your ability to read and interpret the research, your skills in breaking down the science and enabling people to make behavioural change, is all invaluable. Sometimes, what we do can seem simple; it can seem small; it can seem mundane… but, it is so significant and can bring lasting change to a person’s life and health. Look around - how much are the juice cleanses and diet pills people are buying? You as a dietitian should be way more than this.

For help on fees, check out the FDG1 and SENSE factsheets2 and chat to other freelancers. I often ask around when I am quoting on a project, just to check I’m along the right lines; I’ve never found anyone who minds me asking. We are a caring, sharing profession!

It's scary taking this niche approach, but I believe it pays off. What if not enough people need your niche services I hear you ask? Well, take some time to do your research first. Think about how you will offer your services: can you work online as well as in person? Then you can really open up and market yourself nationwide.

Make sure other dietitians know about you; as a profession we should be working with one another as there really should be enough work for us all. Once you get known as an expert in an area, then people will refer to you and promote you.

Finally, almost to contradict myself, just because you work in a niche doesn’t mean you are restricted only to that area. If something big comes along and you want to do it, then go for it. Stepping out of your comfort zone regularly is important, as it will open your eyes to other work opportunities and show you what type of work you like doing. I would never have discovered that I enjoy media work if I hadn’t taken those first few filming opportunities. So, I would encourage everyone, whether old or new to the freelance world, to sit back, take some time to reflect on your niche and where you want to take your business. Remember, sometimes your niche discovers you! www.NHDmag.com February 2018 - Issue 131

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SKILLS & LEARNING

MINDFULNESS, WORKPLACE WELLBEING AND PRODUCTIVITY Nikki Brierley Specialist Dietitian and CBT Therapist

Nikki has been a HCPC Registered Dietitian for eight years and more recently gained BABCP accreditation as a CBT Therapist.

She currently works in a dual role within the Adult Community Eating Disorder Service at Cheshire and Wirral Partnership NHS Foundation Trust.

REFERENCES For full article references please CLICK HERE . . .

Mindfulness continues to be a topic of great interest and is associated with an array of different benefits, including having the potential to increase workplace wellbeing, promote effective working and enhance overall productivity. In a dietetic workplace it could provide all those things and have a positive impact on the dietitian/patient relationship.

In this time of continued austerity, during what can feel like endless budget cuts, ever-increasing demands on time and even job insecurity, there is an obvious risk of reduced wellbeing within the workplace. Literature suggests a direct correlation between workplace wellbeing and workplace performance and, worryingly, recent research has found that the hours spent working are the least happy of our lives and that endemic stress accounts for a large proportion of work place absence and a huge loss in national productivity.1 Not surprisingly, employee wellbeing is an increasing focus for the UK Government, for both the possible health and economic benefits.2 Mindfulness may potentially be beneficial in safeguarding workplace wellbeing and promoting effective working environments. Indeed, a regular mindfulness practice is associated with improved health and wellbeing and increased overall productivity.1 WORKPLACE WELLBEING AND PRODUCTIVITY

Wellbeing can be defined as ‘feeling good and functioning well’. It comprises of an individual’s experience of their life, with comparison to social norms and values. Wellbeing can be considered in two dimensions: 1. Subjective Wellbeing (SWB) - how we think and feel about own wellbeing (i.e. life satisfaction, positive emotion and meaning of life).

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2. Objective Wellbeing (OWB) - based on assumptions about basic human needs and rights (i.e. adequate food, physical health, education, safety).

Workplace wellbeing refers to the levels of wellbeing experienced at work/within the working environment and can also be considered in terms of subjective and objective.

There is a considerable amount of evidence that suggests a positive correlation between SWB and job performance. Literature suggests three main casual mechanisms through which higher levels of SWB can bring about higher workplace performance: 1. Cognitive abilities and processes - allowing creative thinking and problem solving.

2. Attitudes to work - increasing propensity of cooperation and collaboration.

3. Improving physiology and general health - improved cardiovascular health, immunity and quicker recovery from illness and more available energy.

In addition, there is also evidence that suggests that increasing employee SWB may result in higher levels of job performance and, therefore, be conductive to economic growth.2 The Department of Health also describes additional benefits associated with improved wellbeing (summarised in Table 1) and it is easy to see the potential benefit to the wider society (i.e. healthier and happier individuals).

Mind

e

fulness is a natural human c

involves

apabili ty

purpo se

nce in an open and curiou s xperie

and

fully paying attention to our

manne

r.

Table 1: Why wellbeing matters to health • Adds years to life.

• Improves recovery from illness.

• Associated with positive health behaviours in adults and children.

• Influences the wellbeing and mental health of those close to us.

• Effects how staff and health care advisors work.

• Has implications for decisions in patient care practices and services.

• Has implications for treatment decisions and costs.

• Affects decisions about local services.

• May ultimately reduce the health care burden.

Source: Department of Health, Wellbeing: Why it matters to health policy3

MINDFULNESS

Mindfulness is a natural human capability and involves purposefully paying attention to our experience in an open and curious manner.1 Paying attention to the present moment; to our thoughts and feelings and to the world around us, helps us to reconnect with our bodies and sensations, to notice the things we may have taken for granted and reduce the risks of getting caught up in our minds chatter. This allows us to experience the present moment clearly, to

stand back from our thoughts and to identify patterns. In so doing, it is possible to gain a greater understanding of ourselves and have an increased enjoyment of life.4 Mindfulness is recognised as having a potentially positive effect on health and wellbeing and features as one of the government’s five recommended steps to mental wellbeing (summarised in Table 2 overleaf). It is, however, also important to recognise that it is not suitable for everyone and that some adverse effects have been noted. www.NHDmag.com February 2018 - Issue 131

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SKILLS & LEARNING Table 2: Five steps to mental wellbeing Connect

With people around you: family, friends, colleagues and neighbours.

Be active

Find an activity that you enjoy and make it a part of your life.

Keep learning

Learning new skills can give you a sense of achievement and a new confidence.

Give to others

Even the smallest act can count, whether it’s a smile, a thank you or a kind word.

Be mindful

Be more aware of the present moment, including your thoughts and feelings, your body and the world around you. It can positively change the way you feel about life and how you approach challenges.

Source/adapted from: NHS Choices, Five steps to mental wellbeing5

MINDFUL WORKPLACE

Being more mindful generally means noticing the everyday and being aware of our thoughts, feelings, body sensations and world around us.

It allows us to interrupt what can be our default setting of ‘autopilot’ and helps to provide new perspectives. Becoming more mindful takes practice and perseverance and it is with a regular practice that benefits are observed.

Unsurprisingly, The Mindful Nation UK Inquiry by the all-party parliamentary group, found high levels of interest in mindful training in the workplace.1 However, despite this growing interest, common myths about mindfulness can prevent engagement and dispelling these may prove vital to access the possible benefits (see Table 3).

Table 3: Dispelling common myths about mindfulness Common myth

Information to challenge the myth

Mindfulness is a religion

The cultivation of mindfulness is found in many contemplative traditions; however, mindfulness is not owned by any specific group. It is a basic human capability that can be developed with training, practice and patience, doing so does not require a commitment to a specific religion.

Mindfulness and meditation are the same thing

Meditation is one type of activity that can aid in the development and cultivation of mindfulness. There is, however, a range of different types of meditations (much like there is a range of different exercise equipment at the gym designed to exercise different parts of the body). The guided meditation practices within mindfulness training are aimed at developing an attentive, open, curious and caring attitude.

Mindfulness is about ‘emptying your mind’

Mindfulness is not about stopping thoughts or zoning out. It is a form of mental training that allows us to notice our thoughts and bring our awareness back to the task at hand. This strengthens our ability to stay focused and also increases our awareness of the nature of the thoughts that distract us.

The aim of mindfulness is to ‘relax and chill out’

It is a common misconception that mindfulness is about breathing slowly and entering a relaxed state. Mindfulness practice does include some techniques that are aimed at calming an agitated nervous system, however, the breath is mainly used as an anchor so we can notice when the mind has wandered.

Mindfulness training is good for everyone and helps everything

Clinical applications of mindfulness have been shown to be of benefit across a broad population; however, there are some individuals that the training is not appropriate.

The level of training provided is also an important factor and the research outside the clinical area is still in its infancy.

Mindfulness is dangerous

Mindfulness is not dangerous in itself; however, some methods of cultivating mindfulness might not be suitable for some individuals. There is anecdotal that in rare cases some individuals can encounter significant difficulties and turning towards difficult experiences may not be suitable.

Source/adapted from: The Mindfulness Initiative1

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fulness is a natural human c apabili ty ; however, it is e asy to switch t topilot o u e c e n t s a s e h a b f e r o d y t y e l f a u a t o m r e t train t and i he brai n to be more mindful.

Mind

Table 4: Being more mindful at work Be present

Be aware and conscious rather than on autopilot.

Practice short mindful exercises

Even a one-minute mindful exercise can help to train the brain to be more mindful.

Avoid multi-tasking

It is not actually possible to do more than one thing at a time, instead the brain has to quickly switch from one to another. Try focusing on doing one thing at a time.

Use reminders

The brain easily switches back to autopilot, set an alarm, plan in your dairy/calendar to prompt you back to mindfulness.

Slow down

This can seem counterintuitive; however, slowing down can improve efficiency, along with happiness, resilience and health at work.

Reconsider stress

Noticing your heart rate and breathing increasing when stressed can allow you to respond differently (i.e. be aware of the increased energy available to complete the task).

Cultivate gratitude

Gratitude is the antidote to negative thinking and is synonymous with mindfulness.

Being aware of what is going well at work can increase resilience and positivity.

Develop humility

Mindfulness is about accepting who you are and being open to listen and learn from others. To increase humility, consider who has helped you to get where you are today.

Foster acceptance

To be mindful is to accept the current moment just as it is. It does not mean giving up; however, it does involve acknowledging the truth about how things are before trying to change them.

Promote a growth mindset

Mindfulness is about being open to new possibilities. This is in line with a growth mindset believing that things are not fixed and, with effort, intelligence and talents, can be increased.

Sourced/Adapted from: 10 ways to be more mindful at work (2016)6

There is a wide variety of training options available in Mindfulness from self-help books, pod casts, workshops, six to eight week courses, residential retreats to academic studies (differing in quality and standards). Table 4 lists some possible suggestions that could be experimented with to encourage mindfulness whilst at work (and indeed outside the working environment).

SUMMARY

Interest in the practice and potential benefits of mindfulness continues to grow and current research and literature suggests a possible

positive impact on workplace wellbeing. As workplace wellbeing appears to have a direct correlation with productivity and, thus, economic growth, it is not surprising that interests extends to the UK government.

Mindfulness is a natural human capability; however, it is easy to switch to the default of autopilot and it may be necessary to retrain the brain to be more mindful. There are various simple practices that can be incorporated into the workplace to increase mindfulness and with regular practice these may confer a wide variety of benefits that extend beyond the working environment. www.NHDmag.com February 2018 - Issue 131

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DATES FOR YOUR DIARY

MATTHEW’S FRIENDS KETOCOLLEGE KETOGENIC DIETARY THERAPIES BDA CPD approved 1-day Medical Masterclass, 2-day Dietetic programme

19th to 21st June 2018 Crowne Plaza Felbridge, West Sussex Tel: 01342836571 - Email: ketocollege@mfclinics.com Paediatric Nutrition University of Nottingham: School of Biosciences Modules for Dietitians and other Healthcare Professionals 10th-11th March www.nottingham.ac.uk/biosciences

Nutrition and Hydration Week 14th-20th March www.nutritionandhydrationweek.co.uk BDA Live 2016 Incorporating the BDA’s 80th birthday celebrations 16th-17th March QEII Centre, London SW1P 3EE www.bdalive.co.uk/ Advancing Dietetic Practice in Diabetes Training by the British Dietetic Association 21st March 2016 London Road Community Hospital, Derby DE1 2QY www.ncore.org.uk More events on our website here . . .

To place a job ad here and on www.dieteticJOBS.co.uk please call 01342 824073 dieteticJOBS.co.uk

TERRITORY MANAGER (REPUBLIC OF IRELAND) - VITAFLO Vitaflo (International) Ltd are currently looking to recruit a full time Territory Manager on a two-year fixed term contract to cover the Republic of Ireland. The aim of this role will be to drive the sales of Vitaflo’s product range with focus on Vitaflo’s Nutrition Support platform. Key Responsibilities include selling key brands from the Vitaflo product portfolio to customers within the territory; identifying and generating selling opportunities, in addition to following up on leads created by events, exhibitions and other sales and marketing activities. The post holder will meet regularly with existing customers to understand their evolving business needs and will attend conferences and professional association meetings to promote Vitaflo products and brand. Email a copy of your C.V, cover letter and current salary details to chris.richards@vitaflo.co.uk. Closing date: Friday 9th February 2018. For full details, click here . . .

CLINICAL SPECIALIST DIETITIAN - NEONATOLOGY - DUBLIN Permanent, full-time €57,129-€66,294 pro rata per annum The Coombe Women & Infants University Hospital, Dublin is a voluntary teaching hospital with national, regional and area responsibilities for ensuring the optimal health of mothers, women and infants (up to 10,000 pregnant women per annum). We are seeking applications from clinical specialist dietitians in neonatology to work collaboratively with other dietetic and multidisciplinary team members to provide patient-centred care and lead the specialist dietetic service in neonatology. The post holder will work with the multi-disciplinary team including service users to strategically develop, implement and maintain evidence based nutrition policies and procedures with the aim of ensuring optimum dietetic care to infants in CWIUH. Provision of expert dietetic advice on the use of parenteral and enteral feeds in collaboration with consultants, midwifery and pharmacy is key to the role. Informal enquiries for this post can be made to Ms Fiona Dunlevy, Dietitian Manager at +353 1 4085200. Closing date: Monday 26th February 2018. For full details, click here . . .

DIETITIAN - SUSSEX HEALTHCARE We are looking for a dietitian to provide nutrition and dietetic advice, education and support to service users, carers and other health professionals within residential homes for the care of older people, adults with learning and physical disabilities, adults with long-term illness and adults with acquired brain injury. The post holder will provide nutritional assessment and dietary recommendations for an allocated caseload of service users across all Sussex Healthcare sites. The role will be responsible for the nutritional assessment, dietary intervention, monitoring and review of service users, both on oral diet and those who require enteral nutrition and will provide nutritional education for a wide variety of staff and service user groups. To apply, contact: recruit@sussexhealthcare.co.uk.

Tel: 01403 217338. Closing Date: Friday 28th February 2018. For full details, click here . . .

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Sarah Howe Specialist Dietitian Sarah is an experienced NHS Dietitian specialising in the fascinating area of Inherited Metabolic Disorders in adults. In her spare time she enjoys helping her work colleague and good friend, Louise Robertson run her blog 'Dietitian's Life'.

She also loves fitness and spending time with her two girls.

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NHD CPD eArtic Volume 7.18

- 2nd November

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- a review. ‘front door’ by hand. at the NHS HEALTH DIGEST screening print and complete nutritional records, or Malnutrition: print for your relating to: and save or Questions below, download and elderly? in the obese Type your answers

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of CPD for the use and sharing for printing Ltd. reserved. Available from NH Publishing Ltd - All rights permission 2017 NH Publishing purposes without written Copyright © for publishing Not for reproduction

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NHD can help with your CPD For all our eArticles with questions to complete, visit www.NHDmag. com/CPD.html

2018: THE YEAR OF GOALS NOT RESOLUTIONS The New Year has come and gone; we are back on the booze after dry January and eating meat again after Veganuary.

Did you make some New Year resolutions? Are you still sticking to them? Did they include starting afresh with positive healthy changes?

But should we be thinking in terms of ‘resolutions’? What is the actual definition of a resolution? On looking this up it is defined as ‘a firm decision to do, or not to do, something’.

To me this seems very final. Very strict even. There isn’t a lot of room for movement. You resolve to give up chocolate. You have a sneaky chocolate from the box in the staff room at work. You have wavered and failed at your resolution. You’ve done what you said you wouldn’t. This can be very disheartening and often as human beings we do tend to see the negative in a world of positive. Often the easiest thing to do is give up. Well, you’ve failed, so may as well continue failing!

Going cold turkey is a tricky thing to do without a slow, staged response.

Firm resolutions can be easily broken.

Often we do seem to go for the all or nothing approach. Giving up something for a month and then going back to your old ways; this is not teaching you healthier ways.

Setting resolutions should perhaps not be the plan for 2018. Instead of this, goal setting should be approached.

The definition of a goal is ‘the object of a person’s ambition or effort; an aim or desired result.’ When I trained as a dietitian, goals had to be SMART. Specific, measurable, achievable, realistic and timely. Achievable and realistic are key.

The truth is in the definition of a goal.

You are striving to fulfil an aim, but there is no strong pressure and a goal is not as black and white as a resolution. You may have a goal in mind for this year. As healthcare professionals our goal maybe to complete some more CPD and ensure we record and reflect on it. For dietitians, this is especially pertinent as 2.5% of us will get called up for audit in April, having to submit a profile detailing how we have met our CPD standards over the last two years. This is a much more achievable goal than the same resolution to do some CPD every week in 2018.

There are many ways for you to increase your CPD activity: shadowing a colleague, journal club, courses, writing a piece of reflection or reading an article.

The good news is all these approaches contribute to achieving your end goal.

It doesn’t matter if you miss a week.

There isn’t that pressure and a week off will not matter, you will still be working towards increasing your CPD activity.

You won’t have failed, which can be hard to stomach on these cold, wet, dark winter nights.

So, whatever you are planning to achieve for the rest of 2018 (including recording your CPD in a better way), whether it be to improve your health or life in general, try to think of your end result as a goal. Break it down into achievable steps, make it a SMART move, but don’t resolve this year. It is hard work and we are all human. That odd chocolate or missed gym session isn’t a failure, it is part and parcel of achieving our end goal. Much easier to get there and to keep on working at it. www.NHDmag.com February 2018 - Issue 131

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NETWORK HEALTH DIGEST

Coming in the March issue: • Faltering growth

• Dysphagia: meal replacements • Low protein foods

• Elderly care homes

• Caseload management _______ Check whether you are eligible for a FREE subscription to

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

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