The Magazine for Dietitians, Nutritionists and Healthcare Professionals
DIABETES EXAMINED
ORTHOREXIA BOLUS FEEDING FALTERING GROWTH MALDIGESTION IMD WATCH
AN INTRODUCTION TO MINDFULNESS Pages 31-33
NHDmag.com
February 2019: Issue 141
ARE YOU READY FOR IDDSI? WE ARE! The Nutilis Pre-Thickened Range has been re-labelled in line with IDDSI guidelines. For more information visit
www.nutriciahcp.com
This information is intended for healthcare professionals only. The Nutilis range are Foods for Special Medical Purposes for the dietary management of disease related malnutrition and/or dysphagia and must be used under medical supervision.
WELCOME TO . . . Welcome to this first issue of 2019. Not meaning to scare the pants off you, or fast forward this year away, but we only have eight more issues of NHD before we hit 2020! I remember when 2020 seemed like a lifetime away, yet here we are, racing towards it quicker than you can say Network Health Digest. Although 2020 will be a huge year for many, 2019 certainly won’t be overshadowed by it, especially where NHD is concerned. We have another exceptional array of features planned throughout the year, which will focus on the here and now in dietetics and nutrition, providing you with plenty of valuable information and insights. We can’t be any more in the here and now this month, with predictions of the top diets for 2019. Turn to page 9 for Emma Berry’s report on the trending diets for the year ahead. Diabetes mellitus is a condition hard not to come across during your career as a dietitian or nutritionist. In the UK. We have around 4.6 million patients living with diabetes and, according to Diabetes UK, this figure could reach 5 million by 2025. Leona Courtney provides us with a thorough look at this widespread condition in our Cover Story, along with the medical and nutritional interventions available. Conditions and disorders feature big in our February issue. Dr Mabel Blades joins us this month to provide us with information on faltering growth, highlighting the causes, recommendations and guidance, as well as the assessment and management of this complex issue. In her second article in this issue, Mabel provides an overview of maldigestion and how this can be differentiated from malabsorption. And have you come across orthorexia nervosa? It’s a
FROM THE EDITOR
Emma Coates Editor Emma has been a
dietitian growing concern, says Alice Fletcher, registered for 12 years, with manifesting in obsessional behaviour experience of adult around food choices, where a patient and paediatric dietetics. will base their eating on ‘pure food’. With orthorexia, eating clean to the extreme can be far from healthy. Our clinical article in this issue, comes from Louise Walsh, looking at the advantages and disadvantages of bolus feeding, as well as its practical aspects. Louise If you have important news or shares her insights research updates to share with into ensuring patients NHD, or would like to send a letter are supported and to the Editor, please email us at confident when bolus info@network healthgroup.co.uk feeding is required. We would love to Enhancing your skills hear from you. and learning doesn’t end there, as we welcome Harriet Smith to NHD with her first article delving in to the world of mindfulness, asking what it is and how we can become mindful eaters. Then we turn to our regular columns including IMD Watch brought to us this month by Suzanne Ford, NSPKU Dietitian and Anita MacDonald, Specialist Metabolic Dietitian, who calculate the cost of a special diet, with particular reference to the low-protein diet. Face to Face is a regular favourite from Ursula Arens who, this time, interviews Dr Paul Sacher, co-founder of MEND (Mind, Exercise, Nutrition . . . Do it!). Sit back, relax and slow down time with your copy of NHD! Emma
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3
12 COVER STORY Diabetes examined 6
News
9
Diet trends
Latest industry and product updates
Popular diets for 2019
17 FALTERING GROWTH Dietetic management
43 F2F Interview with Dr Paul Sacher 46 A day in the life of . . . A freelance dietitian
22 Orthorexia
48 DIETETICS ON WHEELS The challenges
A modern-age eating disorder
27 Bolus feeding Advantages and disadvantages 50 The Nutrition Society Advancing nutritional science
31 MINDFULNESS An introduction
52 Events, courses & dieteticJOBS Dates for your diary
35 IMD watch The cost of a low-protein diet 40 Maldigestion or malabsorption The differences explained
and job listings
53 Dietitian's life Veganuary: A challenge too far?
Copyright 2019. 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
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Phone 01342 825349 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
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@NHDmagazine ISSN 2398-8754
FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best for babies
THE FIRST AND ONLY EHF
TO CONTAIN GOS/FOS PREBIOTICS
Aptamil Aptamil Pepti Pepti Clinically proven to REDUCE allergic manifestations for up to five years1–3
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cows’ milk allergy is extensively hydrolysed formula†
References: 1. Arslanoglu S et al. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the fi rst two years of life. J Nutr. 2008;138:1091-5. 2. Arslanoglu S et al. Early neutral prebiotic oligosaccharide supplementation reduces the incidence of some allergic manifestations in the fi rst 5 years of life. J Biol Regul Homeost Agents. 2012;26:49-59. 3. Pampura AN et al. Ros Vestn Perinatol Paediat 2014;4:96-104
IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cows’ milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is suitable for babies over 6 months as part of a mixed diet. † For the management of mild to moderate IgE-moderated cows’ milk allergy the iMAP guideline recommends an Extensively Hydrolysed Formula (EHF) as the fi rst step for formula feeding or mixed feeding (if symptoms only with introduction of top-up feeds) infants.
18-044 (GOS/FOS)/Date of Prep: March 2018 © Danone Nutricia Early Life Nutrition 2018
Healthcare Professional Helpline: 0800
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NEWS
Emma Coates Editor Emma has been a registered dietitian for 12 years, with experience of adult and paediatric dietetics.
To book your company's
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NHS LONG-TERM PLAN (LTP) LAUNCHED Launched at the beginning of January, the 10-year LTP includes measures to prevent 150,000 heart attacks, strokes and dementia cases and provide better access to mental health services for adults and children. It’s a new plan for the NHS to improve the quality of patient care and health outcomes, setting out how the £20.5 billion budget settlement for the NHS, originally announced by the PM in summer 2018, will be spent over the next five years.
Planning for the next 10 years of the NHS A guide to help
your discussion
s
The NHS is makin g 10 years of the NHSa plan for the next We are working with staff, partners and people and families, public to get the plan right This document will help everyone think about the same big questions www.en Email england gland.nh.ltp@nh s.uk s.net Website www.en gland.nhs.uk
Who will benefit? The plan has been developed in partnership with frontline health and care staff, patients and their families. It aims to improve outcomes for major diseases as mentioned above, also including cancer, heart disease and respiratory disease with measures to: • improve out-of-hospital care, supporting primary medical and community health services; • ensure all children get the best start in life by continuing to improve maternity safety, including halving the number of stillbirths, maternal and neonatal deaths and serious brain injury, by 2025; • support older people through more personalised care and stronger community and primary care services; • make digital health services a mainstream part of the NHS, so that in five years, patients in England will be able to access a digital GP offering. For more information visit: www.longtermplan.nhs.uk BDA response to the plan BDA Chair, Caroline Bovey, and England Board Chair, Dr Brian Power, gave their initial thoughts on the plan via social media on 9th January: "The LTP sets out a laudable and welcome ambition to improve the NHS and make best use of the funding made available over the next five years. It’s positive to see strong commitments to strengthening and diversifying primary and community care, supporting mental health services and embracing new technology. However, it was disappointing not to see any reference to the role of dietitians in areas such as malnutrition and frailty in the elderly, obesity and Type 2 diabetes, or the need to recruit more dietitians to help manage and prevent these conditions." To read Caroline and Brian’s full thoughts on the LTP click here . . .
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NEWS DEPARTMENT OF HEALTH AND SOCIAL CARE OPEN CONSULTATION (DHSC): RESTRICTING PROMOTIONS OF FOOD AND DRINK HIGH IN FAT, SUGAR AND SALT Published 12th January 2019 The government aims to reduce excessive eating and drinking of food and drink products high in fat, sugar and salt (HFSS), which can lead to children becoming overweight and obese. It’s also aiming for businesses to promote healthier food and drink, to help people make healthier choices. In so doing, the DHSC is seeking views on government plans to restrict the promotion of HFSS food and drink products by location and price. Set out in Childhood obesity: a plan for action, chapter 2, the proposed plans are to be discussed in this consultation which is asking to share your thoughts on: • restricting volume-based price promotions of HFSS food and drink that encourage people to buy more than they need, for example, ‘buy one, get one free’ and free refills of sugary soft drinks; • restricting the placement of HFSS food and drink at main selling locations in stores, such as checkouts, aisle ends and store entrances. This consultation is open until the 6th April and if you wish to contribute, click here . . .
SHOULD OBESITY BE RECOGNISED AS A DISEASE? In January, the Royal College of Physicians (RCP) released an obesity position statement calling for obesity to be urgently recognised as a disease by government and the broader health sector; warning that until this happens, its prevalence is unlikely to be reduced. According to Public Health England, in 2015, 63% of adults were classed as being overweight or obese. In 2015 to 2016, 19.8% of children aged 10 to 11 were obese and a further 14.3% were overweight. The RCP wants to see obesity recognised as an ongoing chronic disease to allow the creation of formal healthcare policies to improve care both in doctors’ surgeries and hospitals, and so that significant and far-reaching preventative measures can be put in place. As well as encouraging prevention, treatment and greater empathy with patients, the RCP wants to see a change to public discourse about obesity, so that those with the condition are no longer blamed for it. Professor Andrew Goddard, RCP president, said: “It is important to the health of the nation that we remove the stigma associated with obesity. It is not a lifestyle choice caused by individual greed, but a disease caused by health inequalities, genetic influences and social factors. It is governments, not individuals, that can have an impact on the food environment through regulation and taxation, and by controlling availability and affordability. Governments can also promote physical activity by ensuring that facilities are available to local communities, and through legislation and public health initiatives.” Click here . . . to download the full statement.
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Exploring the latest views about eggs and health Network Health Digest and British Lion eggs have teamed up to find out more about what our readers know about eggs. There are many myths and misconceptions about this nutrient-packed food – are you up-to-date with the latest scientific thinking?
Test your knowledge by taking our online survey. This will only take three minutes and you will be entered into a prize draw to win 8 prizes of ÂŁ25 each in UK shopping vouchers. Enter here . . .
Look out for more exciting egg news in the coming months. For more about eggs and health and the latest research visit egginfo.co.uk. For the terms and conditions click here . . .
DIET TRENDS
TOP DIETS 2019: WHICH DIETS ARE POPULAR AND WHY DOES THIS MATTER?
Despite a growing increase in the body positivity and healthy at every size movement,1 diets are still big business. Although diets often have the aim of weight loss, it might not always be the goal. This article discusses some of the most talked about diets and considers the impact these may have on nutrition. In January, media company U.S. News and World Report released their rankings for their ’41 best diets overall’.2 The experts3 who ranked the diets range from academics, researchers, clinicians, nutritionists and dietitians and the diets have been rated in a number of categories including ease of compliance, effectiveness for heart health, effectiveness for weight loss, nutritional completeness and health risks. In the overall diet ranking, the top diet for 2019 is the Mediterranean diet, the DASH diet coming second and the flexitarian diet third (see overleaf). These results have also been reported in UK news and magazines such as Good Housekeeping and The Sun.4,5,7 In 2018, the BDA provided the NHS with guidance on some of the most popular diets in the UK. This can be found on the NHS website,6 providing information on 12 diets (with a BDA verdict), including the 5:2, the Dukan, the Paleo, New Atkins diet and slimming club diets, such as Weight Watchers and Slimming World (see overleaf). Although some of the diets listed are the same as those ranked by U.S. News, the top three – Mediterranean DASH and flexitarian – are not mentioned, suggesting that these are either not popular in the UK or, perhaps, the NHS want to focus on weight loss diets.
Certain diets can have an impact on nutritional status, with physical and mental side effects occurring early, depending on the diet being undertaken.6 If, for example, an individual is following a diet that limits certain food groups, they may become nutritionally deficient if they are not aware of the risks involved.6 Therefore, it is important that people wishing to follow these popular diets are made aware of the risks involved and know how to counter the impact. Many diets refer individuals to a healthcare professional before undertaking them, but is this sufficient to ensure individual safety? There have already been various articles on which foods are expected to be trendy in 2019, hinting towards plantbased foods, probiotics and wholefoods, plus a projected rise in the popularity of the flexitarian diet.8 Information on the most popular diets is widely advertised to the public on social media and in other channels, but the impact and risks of such diets are not so forthcoming. Providing individuals with guidance from trusted sources on popular diets is vital, to ensure that the correct information on a diet’s risks and impact is clearly understood. Providing information on eating plans would also be beneficial so that individuals are aware of the different options available to them. This might encourage a more sustainable lifestyle change, focusing on overall health improvement, as opposed to weight loss alone.
Emma Berry Associate Nutritionist (Registered) Emma is working in Research and Development and is enjoying writing freelance nutrition articles.
REFERENCES Please visit the Subscriber zone at NHDmag.com
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9
DIET TRENDS
An overview of the 'top' diets 2019 Diet
Summary
One pro
One con
Mediterranean diet
This is not a structured diet, instead it is based on the eating pattern of the Mediterranean. This focuses on eating more fruit, vegetables, olive oil, fish and seafood, while reducing other foods such as red meat.3
This eating style focuses more on improving health rather than weight loss necessarily, so could appeal to a range of people.3
Some of the ingredients on the Mediterranean diet can be expensive, such as olive oil and some fresh food.3
A diet plan focusing on promoting heart health, this encourages followers to reduce foods high in sodium, saturated and trans fats.
This diet encourages eating more fibre food.
The DASH diet can be restrictive as there is no room for added sugar or excess salt.
This is an unstructured eating plan, which allows followers to adopt a flexible vegetarian diet – eating mainly vegetarian foods, but opting for meat options occasionally.
This eating plan is flexible and doesn’t cut out any food groups.
There is limited evidence on long-term flexitarian health outcomes, as most large diet surveys have compared meat eaters, vegetarians and vegans.
Intermittent fasting two days a week, five days eating normally
Individuals may find it easier to stick to two days restrictive eating better than a seven-day diet.
Restricted eating and skipping meals can have negative side effects, such as reduced concentration, or headaches.
Dukan diet
Four-phased eating plan. Phase 1 is a high protein and very low carbohydrate diet. The next three phases slowly increase the amount of carbohydrates.
The plan does not involve counting calories or weighing out food.
Removal of carbohydrates can have an impact on bowel movements.
Paleo diet
The foods allowed on this plan mimic foods eaten by our early ancestors. Generally, this means the removal of processed foods, dairy and some carbohydrates.
Individuals are encouraged to eat less processed foods, replacing them with fruit and vegetables. This could increase nutritional status and fibre intake.
Cutting out food groups entirely without a medical need to do so, could lead to nutritional deficiencies.
New Atkins diet
Four-phased diet plan, which reduces carbohydrates and reintroduces them slowly over the next three phases. There are no restrictions on fat intake.
People are encouraged to remove processed carbohydrates and alcohol.
The high intake of protein and fat could have an impact on heart health. There is also an encouragement to add salt, which is concerning.
DASH (Dietary Approaches to Stop Hypertension) diet
Flexitarian diet
5:2 diet
10
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Diet
Summary
One pro
One con
Alkaline diet
Foods are split into acid producing foods or alkaline foods. Followers are encouraged to reduce acid producing foods and increase alkaline food consumption.
The acid producing foods include meat, sugar, alcohol and processed foods. The alkaline foods include fruit and vegetables, so it may follow current healthy advice.
Reducing some food groups, such as dairy can have an effect on important nutrients such as calcium. This needs to be carefully considered.
South Beach diet
This is a phased diet, which involves low-GI foods. Low-GI carbohydrates are increased throughout the phases. Individuals are also encouraged to exercise.
Not all individuals have to start on phase 1 of the diet, you can choose to start on phase 2 which is less restrictive.
Phase 1 is very restrictive, so followers will likely miss out on some important nutrients.
Slimming World diet
This diet encourages followers to select low-fat foods over high fat foods. Followers do not need to calorie count or restrict certain food groups.
Exercise is encouraged as part of the diet, with support also available in a group setting.
Foods that are higher in energy and eaten as treats are given a ‘syns’ value. This could result in negative food relationships.
SlimFast diet
This is a meal replacement diet. Followers replace two meals a day with SlimFast replacement options (eg, shakes).
Using meal replacements can reduce the preparation time and organisation required in some diet plans.
Meal replacements alone are unlikely to provide a long-term solution for weight loss.
LighterLife diet
This is a very low calorie diet providing planned meal-replacement food packs and weeklycounselling.
Counselling may help some followers understand their relationship with food better, to allow for longerterm changes.
Very low calorie diets can have physical and mental side effects, such as feeling isolated, or insomnia.
WeightWatchers diet (Flex)
Essentially, a caloriecontrolled diet which assigns points to foods. Exercising earns additional points. There are options to attend group meetings.
There are no restrictions on food groups in this plan.
Working with a points system may be time consuming for new followers.
Rosemary Conley diet
A diet plan focusing on low-fat and low-GI foods, while incorporating regular exercise into the follower’s lifestyle. There is an online community and resources to support followers.
The exercise is a vital part of the plan, with online videos for a range of abilities.
The diet plan may be challenging to incorporate when eating out or when socialising.
Sugar-free diet
This plan involves followers limiting or omitting sugar from their diet completely.
Cutting down on foods high in added sugar can be good, as the UK population consumes too much sugar.
Cutting out all sugar, including sources such as fruit or milk, does not result in a balanced diet.
(adapted from various sources)3,6,8,9 www.NHDmag.com February 2019 - Issue 141
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CONDITIONS & DISORDERS
DIABETES EXAMINED
The classification, diagnosis and management of diabetes are looked at in this article, along with medication and lifestyle interventions. Leona Courtney Diabetes Specialist Dietitian Leona has been working for over three years as a clinical dietitian. She currently works in St James's Hospital Dublin as a Diabetes Dietitian. She has a keen interest in running and enjoys cooking.
REFERENCES Please visit the Subscriber zone at NHDmag.com
12
Diabetes mellitus is defined as a metabolic disorder characterised by elevated blood glucose levels with disturbances of carbohydrate, protein and fat metabolism due to insufficient insulin production, insulin action or both.1,6 The chronic hyperglycaemia of diabetes is associated with long-term complications, including neuropathy with risk of ulcers and amputations, retinopathy with potential loss of vision and nephropathy leading to renal failure. Individuals who present with diabetes are also at heightened risk of peripheral, cerebrovascular and cardiovascular disease (CVD). Heart disease and stroke are two to four times higher in individuals with diabetes compared to their non-diabetic counterparts,2 with hypertension and hypercholesterolemia commonly evident.2-4 The classification of diabetes can be attributed to four main types: Type 1 diabetes, Type 2 diabetes, gestational diabetes mellitus (GDM) and maturityonset diabetes of the young (MODY). The majority of individuals will present with either Type 1 or Type 2. The presentation of diabetes mellitus varies from asymptomatic Type 2 diabetes to the acute, life-threatening diabetic ketoacidosis (DKA) or a nonketotic hyperosmolar state, which may develop and lead to coma and, if effective treatment is not provided, death. DKA occurs when blood glucose levels rise >11mmol/L accompanied by a lack of insulin which causes the body to switch to burning fatty acids and producing acidic ketone bodies.5 Short-term consequences of uncontrolled diabetes include hypoglycaemia (fasting blood glucose
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levels <4mmol/L), which can lead to loss of consciousness, and hyperglycaemia (blood glucose levels >7mmol/L). Both hypo- and hyperglycaemia can present a substantial clinical impact in terms of mortality, morbidity and quality of life.4 Diabetes is complex, in that several pathogenetic processes are involved in its development. These processes occur following exposure to a certain causation factor which destroys the β-cells of the pancreas, resulting in subsequent insulin deficiency, or impaired insulin sensitivity. Known causes include; certain viruses, endocrinopathie, diseases of the exocrine pancreas and the immune system, drug or chemical induced diabetes and gene mutations.4 CLINICAL DIAGNOSIS
The clinical diagnosis of diabetes is characterised by the presence of a wide range of presenting symptoms, mainly; polyuria, polydypsia, unexplained weight loss, fatigue and blurred vision and is confirmed by documented hyperglycaemia.6 Depending on the type of diabetes, the occurrence of symptoms may be rapid (typical of Type 1 diabetes) or slow onset (typical of Type 2 diabetes). In Type 2 diabetes, often symptoms are not severe, or may be absent and, consequently, hyperglycaemia sufficient to cause pathological and functional changes may be present for a long time before a diagnosis is confirmed.6 Gestational diabetes mellitus (GDM) GDM is defined as any degree of glucose intolerance with onset or first recognition during the third trimester of pregnancy.6 GDM complicates 4% of pregnancies in
the UK (NHS, 2014).5 However, the diagnosis of GMD is contentious, in that the NICE diagnostic criteria is higher than that recommended by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) – fasting blood glucose of >5.6mmol/L compared to the lower cut-off of >5.1mmol/L – therefore resulting in fewer diagnoses and lower prevalence rates.7,8 Risk factors for the development of GDM include: obesity, personal history of GDM, family history of diabetes and glycosuria. The management of GDM varies between individuals where some women can manage their condition solely via diet and lifestyle interventions, whereas others will require the use of medications or the administration of insulin for successful management. GDM usually resolves following pregnancy, although it has been shown to increase the patient’s chance of developing Type 2 diabetes in later life.5 Diabetes of the young (MODY) MODY is a term used to describe several forms of diabetes which are associated with monogenetic defects in β-cell function and which are frequently characterised by the onset of hyperglycaemia in those <25years. MODY is a rare condition, which has a strong genetic link and is known to affect 1-2% of the population.9 MODY presents as impaired insulin secretion with minimal or no defects in insulin action. Again, the treatment for MODY varies depending on its type, where some individuals can effectively control their condition without the use of medication, whilst others require multiple daily injections of insulin in order to achieve good glucose control. As already stated, the patient majority will present with either Type 1 diabetes or Type 2 diabetes. The aetiology and causation of these two conditions differs greatly. Type 1 diabetes This comprises 5-10% of those with diabetes and was previously encompassed by the terms of insulin-dependent diabetes or juvenile-onset diabetes. These terms are now less commonly used given the increased number of young individuals being diagnosed with Type 2 diabetes and the heightened use of insulin therapy in the management of Type 2 diabetes (which will be
discussed in this article). It is believed that Type 1 diabetes is an autoimmune condition that occurs as a result of cellular-mediated destruction of the β-cells of the pancreas. This leads to the body being unable to produce insulin, causing hyperglycaemia. The destruction of the β-cells is linked with multiple genetic predispositions and is also related to environmental factors that are poorly understood. Various triggers have been identified, including; certain viruses, vaccines and some medications.10 Type 2 diabetes This is the most common form of diabetes and accounts for 90-95% of those with diabetes. It was previously referred to as non-insulin-dependent diabetes, or adult onset diabetes. Type 2 diabetes is a preventable, but progressive metabolic disorder, which also involves a complex relationship between both genetics and environmental factors. Individuals diagnosed with Type 2 diabetes present with impaired insulin sensitivity and usually have relative (rather than absolute) insulin deficiency, either of which may be the predominant feature.4,11 Symptom occurrence in Type 2 diabetes is generally a slow process that develops over a prolonged period of time, unlike the rapid onset of presenting symptoms usually evident in those with Type 1 diabetes. Due to the slow presentation of symptoms, many individuals with Type 2 diabetes simply associate their symptoms with increased age and, therefore, fail to act upon them. As a result, the condition can often go undiagnosed for many years. It is estimated that there are approximately one million individuals living in the UK with undiagnosed Type 2 diabetes.12 However, such undiagnosed diabetes carries the risk of insidious tissue damage. As previously stated, it is well documented that patients with Type 2 diabetes often have pathological degrees of hyperglycaemia for several years before a diagnosis is made.2,4 Although the specific aetiologies of Type 2 diabetes are currently unknown, disease development is associated with several risk factors. These are both modifiable and nonmodifiable, including increasing age, Asian ethnicity, genetics, lack of physical activity and obesity.13,14,15 www.NHDmag.com February 2019 - Issue 141
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CONDITIONS & DISORDERS
Obesity is the most potent risk factor for Type 2 diabetes
An abundance of high quality research has shown that there is a strong inheritable genetic connection with the development of Type 2 diabetes, where individuals who have a first degree relative with the condition are at a substantial increased risk of disease development.4,16,17 The genetics are complex and not fully understood, but it is hypothesised that the condition is associated with several genes. It is speculated that the development of Type 2 diabetes occurs when a diabetogenic lifestyle (excessive caloric intake, insufficient caloric expenditure, obesity) is superimposed upon a susceptible genotype.1 OBESITY AND TYPE 2 DIABETES
Obesity is the most potent risk factor for Type 2 diabetes, with research showing that it accounts for 80-85% of the overall risk of disease development.15 It is suggested that abdominal obesity promotes adipose tissue to release proinflammatory cytokines, which in turn decreases the bodyâ&#x20AC;&#x2122;s sensitivity to insulin. This is known as insulin resistance.18 Furthermore, adipose cells possess the ability to secrete hormones that contribute to insulin insensitivity.19 Consequently, it is now well documented that there is an inverse relationship between BMI and insulin sensitivity, where an increase in BMI reflects a corresponding reduction in insulin sensitivity.20 This information is worrying given the spiralling levels of overweight and obesity currently evident in the UK population.21 As already stated, historically, Type 2 diabetes mainly presented in 14
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adults, however, this is no longer the case.1,4 The increased prevalence of Type 2 diabetes in young individuals coincides with the increased occurrence of obesity in the same population group, which has more than tripled in the past 25 years.21 Research has shown that there is a convincing link between ethnicity, obesity and the risk of developing Type 2 diabetes.3 Individuals from South Asian descent are six times more likely to develop the condition compared to their Caucasian counterparts.3 Similarly, those from African and Afro-Caribbean background have three times the increased risk of developing Type 2 diabetes when compared to those from a non-African background.3 Generally, these individuals present with a smaller body frame which increases their likelihood of central obesity and, therefore, the development of Type 2 diabetes. These findings have led to NICE recommending that individuals from these backgrounds maintain a BMI <23kg/m2 to reduce their risk of disease development.22 For individuals diagnosed with diabetes, the aim of successful management is to maintain quality of life and reduce diabetes related complications, predominantly by achieving glycosylated haemoglobin (HbA1c) levels that are within the target range of 48mmol/mol to 53mmol/mol (6.5%-7%), as recommended by NICE and Scottish Intercollegiate Guidelines Network (SIGN).23,24 HbA1c is a well-recognised marker of glycaemic control in those with established diabetes as it reflects average glucose levels over the past two-to-three-month period.24 MANAGEMENT AND CONTROL
The management of Type 1 and Type 2 diabetes differs mainly due to the fact that there is a complete lack of insulin production in those with Type 1 diabetes. Therefore, to effectively manage the condition, subcutaneous insulin is always necessary for those diagnosed with Type 1 diabetes. This may be administered via daily injections or through the use of an insulin pump. There are many different types of insulin including rapid acting, short acting and intermediate and long acting insulin. Traditionally, many people with Type 1 diabetes were managed with a twicedaily insulin regimen; however, this allowed
no flexibility in terms of diet or exercise and, therefore, we have moved towards multiple daily insulin injections to improve overall diabetes control and quality of life. This has involved taking basal insulin once or twice daily along with bolus insulin whenever carbohydrates (CHOs) are consumed. It is also necessary that people on this regimen are accurately identifying and counting their CHO to adjust their insulin accordingly. For those on insulin pumps, only one type of insulin is used – rapid acting. A small device is worn on the outside of your body. A tube connects a reservoir of insulin to a catheter that’s inserted under the skin of the abdomen. There is also a wireless pump option. Pumps are programmed to dispense specific amounts of rapid-acting insulin automatically. This steady dose of insulin is known as your basal rat, and it replaces whatever longacting insulin the patient was previously using. When CHOs are consumed, the pump is programmed with the amount of CHOs and current blood glucose levels and it will give you what’s called a bolus dose of insulin to cover meals and to correct blood sugar if it’s elevated. When using the pump, insulin to CHO ratios will have also been programmed into the device. Different basal rates can also be set for when additional insulin is required, such as dawn phenomenon and less insulin, eg, exercise. An insulin pump combined with a continuous glucose monitoring (CGM) device may provide even tighter blood sugar control. With regard to the management of Type 2 diabetes, dietary advice for weight loss is the first line of treatment and may or may not be combined with one or more of a wide range of therapeutic options.24 For some individuals with Type 2 diabetes, the condition can be managed solely via diet and lifestyle interventions; however, this is seldom sufficient. Thus, pharmacological adjuncts are required in early management for the majority of patients. Metaformin Insulin production occurs in the β-cells of the pancreas. However, the gradual destruction of these cells and the decline in pancreatic function is a progressive phenomenon in those with Type 2 diabetes, therefore, the intensification of medication is a common practice.1 Metformin is an oral hyperglycaemic agent (OHA) commonly
used as first-line treatment for those with Type 2 diabetes and who are overweight (BMI >25kg/ m2; Asians >23kg/m2).24 Metformin works by reducing glucose output via suppression of gluconeogenesis. It also improves insulin action and reduces post-prandial glucose levels by increasing glucose uptake into the muscles where it is stored.25 The main side effects include nausea, diarrhoea and abdominal discomfort. Sulphonylureas If metformin fails to achieve adequate glucose control (4mmol/L to 7mmol/L pre-meals), then another type of OHA, sulphonylureas, can be added for use as a dual therapy. Sulphonylureas increase endogenous release of insulin from the pancreatic β-cells. However, patients who take sulphonylureas have an increased risk of hypoglycaemia, compared to those on diet alone.26 Recent research has shown that 1% of individuals on sulphonylureas experienced hypoglycaemia compared to 0.2% for those treated with metformin.26 Furthermore, a greater degree of weight gain is noted in those on sulphonylureas with studies showing an approximate weight gain of 5kg within the first six months of commencement, compared to those on a placebo.27 Other inhibitors Thiazolidinediones and Dipeptidyl preptidase-4 (DPP-4) inhibitors are other forms of OHAs, which can be used when sulphonylureas are not well tolerated, or if additional drugs are required to achieve good glucose control. Thiazolidinediones increase whole body insulin sensitivity and reduce glucose levels through two main mechanisms: increased tissue uptake of glucose and decreased hepatic glucose production.28 Thiazolidinediones require a sufficient amount of insulin production to be able to exert a therapeutic effect, therefore, their use is blunted in some individuals. It should be noted that thiazolidinediones also promote weight gain.28 DPP-4 inhibitors work by inhibiting the activity of the enzymes DPP-4 and, therefore, prolong the activity of the incretin hormone glucagon-like peptide-1 (GLP-1). GLP-1 analogues GLP-1 analogues are a relatively new injectable therapy that work by mimicking endogenous www.NHDmag.com February 2019 - Issue 141
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CONDITIONS & DISORDERS GLP-1 activity. GLP-1 is an incretin hormone produced in the intestinal l-cells of the pancreas and secreted in the gut following nutrient ingestion. GLP-1 works by increasing the production of insulin when needed and reducing the manufacturing of glucose when not needed.29 The physiological effects that GLP-1 provides are of much interest as they can provide huge clinical benefit for diabetes management.24 These benefits include; delayed gastric emptying, the inhibiting of glucagon secretion from the β-cells of the pancreas along with decreasing postprandial glucose levels. In the pancreas, GLP-1 increases β-cell mass, therefore promoting insulin secretion and improving insulin sensitivity.30 Furthermore, GLP-1 facilitates insulin gene transcription and neogenesis, both showing significant clinical relevance in the treatment of diabetes. GLP-1 is known to play a role in the central nervous system where is induces satiety and suppresses the appetite.30 Unfortunately GLP-1 is rapidly metabolised by the body and, therefore, the benefits are short lived. However, the administration of GLP-1 analogues can result in prolonged action of GLP-1 hormones, which could have profound benefits for the successful management of Type 2 diabetes. In most guidelines, GLP-1 analogues are currently prescribed as a triple therapy, alongside metformin and sulphonylurea.23,24 GLP-1 analogues have consistently been shown to significantly improve glucose control in those with suboptimal blood glucose levels.31,32 Not only do they improve glycaemic control, but they also facilitate weight loss and reduce both blood pressure and lipid levels, therefore reducing overall CVD risk.33,34 These benefits can be witnessed within the first three months of treatment commencement.35 Insulin If medication and lifestyle interventions fail to achieve good glucose control in Type 2 diabetes, insulin therapy is generally the next option.24 The benefits that insulin provides in terms of assisting in achieving good glycaemic control are well known.24 However, it should be noted that not only does the commencement of insulin administration promote an average weight gain of 5kg-7kg, which is usually greatest at the beginning 16
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of insulin use,19,35 it also increases an individual’s risk of hypoglycaemia. This is of a huge concern as, not only is hypoglycaemia dangerous, but it may impact upon compliance, limiting the attainment of lower glycaemic targets.1,37 Given that weight loss is a fundamental aspect for the successful management of Type 2 diabetes, the introduction of insulin can, therefore, be contraindicated. Interestingly, from 1991-2010 there was a sevenfold increase in the number of individuals with Type 2 diabetes who were commenced on insulin.38 This heightened use may be as a result of the increased frequency of diabetes mellitus along with the failure to adequately control diabetes via dietary and lifestyle interventions/weight loss and the use of OHAs. CONCLUSION
Despite this wide range of therapeutic options, many individuals still fail to meet the recommended HbA1c target range (HSCIC, 2014).21 This is worrying given that an abundance of research has shown that the achieving of HbA1c levels close to the target range can help facilitate a decline in both the short- and longterm complications of diabetes in addition to promoting quality of life and longevity.1,3,39,40 Lowering HbA1c levels by as little as 1% can result in a reduction of retinopathy by 38%, nephropathy 28%, neuropathy 28% and cardiovascular events by as much as 57%.41 These statistics are of much importance given the financial burden placed on the NHS budget for the treating of these complications, with diabetes costing the NHS £10 billion per annum, with most of this being spent on diabetes comorbidities, a figure projected to only get worse.42 Good management of diabetes can lower these complications and subsequently save the NHS substantial money. A contributing factor to the failing of good glucose control may be the undesirable side effects, as discussed previously, experienced with the utilisation of many of these medications, which can subsequently hinder compliance rates.43 Thus, therapies that allow the attainment of glycaemic control without promoting weight gain and with minimal side effects, are in high demand, where they can allow evidence-based cost effective care.
PAEDIATRIC
FALTERING GROWTH Faltering growth is an area where dietitians can provide invaluable support. This article looks at the underlying problems/causes, recommendations and guidance, as well as the assessment and management of faltering growth. As a freelance dietitian, I receive all sorts of enquiries from people about diet and nutrition, including questions from parents who are extremely concerned that their children are not gaining weight and are smaller than their peers. The majority of the enquiries are from parents of babies, but I also receive concerns from parents of older children and all are extremely worried about the situation. Normally, I advise that they seek support from a dietitian locally, but occasionally, if they have already seen a dietitian and require extra support, I will get involved. On occasion, I am also asked for an opinion from social workers and others concerned about children who appear not to be growing as expected. The area of faltering growth is one in which many NHS dietitians are asked for advice by other healthcare professionals and, certainly, this was my experience when I worked in the NHS. A SYMPTOM OF UNDERLYING PROBLEMS
Faltering growth is defined as a significant interruption in the expected rate of growth, of height and/or weight of a child compared to other children of similar age and sex during early childhood. It is often a gradually evolving situation that can go undetected, particularly in children whose parents do not frequently access healthcare for them. In the 1940s, it was suggested that the condition could be due, not just to poor nutrition, but also emotional deprivation and under
Dr Mabel Blades Independent Freelance Dietitian and Nutritionist
stimulation.1 Medical conditions, such as gastrointestinal and neurological disorders, congenital heart disease, metabolic disorders, food allergies and intolerances and cystic fibrosis, can all be a cause of faltering growth. It is also well documented that no reason for faltering growth may be found. However, the most common cause of faltering growth tends to be undernutrition compared with the child’s nutritional needs. While the causes of this tend to be multifactorial, they are normally related to diet and feeding behaviour.2 Looking back over the last year through my contacts, poor feeding in breastfed babies was due to the baby being ‘tongue tied’ and in formula-fed babies, inappropriate milk was being used. On one occasion, faltering growth was due to inappropriate weaning behaviour. Occasionally, poor growth can be due to neglect of the child due to parental issues, such as bereavements, addictions and stress, as well as lack of knowledge. Faltering growth is not really a diagnosis; rather a symptom of other underlying problems. An early recognition of the issue and a full investigation and diagnosis of the underlying causes of the faltering growth rely on good awareness by
Mabel is a Registered Dietitian, a member of the BDA and NAGE, Food Counts, Older people Specialist Group and the Freelance Dietitians Group. All aspects of nutrition enthuse her and she is passionate about the provision of nutritional information to people in assisting their understanding of any diet.
REFERENCES Please visit the Subscriber zone at NHDmag.com
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To order a Fortini sample direct to your patient today, please visit www.nutriciaproducts.com/samples/paediatrics This information is intended for Healthcare Professionals only. Fortini products are Food for Special Medical Purposes for the dietary management of disease related malnutrition and growth failure in children from one year onwards and must be used under medical supervision. Samples can be provided to patients upon the request of a Healthcare Professional. They are intended for the purpose of professional evaluation only. Nutricia Advanced Medical Nutrition, White Horse Business Park, Newmarket Avenue, Trowbridge, Wiltshire, BA14 OXQ, UK
For parents who are concerned about the lack of growth of their infant, it is important that their concerns are treated seriously and that the infant’s growth is properly measured and compared with standards. healthcare professionals, especially health visitors who are likely to see an infant more regularly than others. When parents seek advice about their offspring’s health, they may not consider that their infant has faltering growth, but another issue, such as gastrointestinal symptoms. Thus, it is important that healthcare professionals are aware of the need to assess the child. For parents who are concerned about the lack of growth of their infant, it is important that their concerns are treated seriously and that the infant’s growth is properly measured and compared with standards. If not properly assessed, faltering growth can persist. It is associated with reduced adult height, impaired academic performance and an increased incidence of behavioural and psychological disturbances. SIZE OF THE PROBLEM
There is a great variation in the reported prevalence of faltering growth in paediatric patients. On the Danone Nutricia Research website, a range of 5-50% is quoted and those at highest risk are said to be below the age of five.3 Faltering growth used to be called failure to thrive which was unfortunate, as many parents could feel that they were failing in the way they looked after their children and could feel that they were being blamed for their children
not growing. The term failure to thrive is still occasionally used today, which can be upsetting for parents. The extremely popular website ‘Mumsnet’, which provides advice on parenting and all aspects of childcare, has numerous discussions about faltering growth, plus it was noted that reassurance was given to mothers who were anxious about being told that their infant was failing to thrive.4 WEIGHTS OF BABIES AFTER BIRTH
During the first few days of life, weight loss is normal but this usually stabilises after three to four days and the baby normally returns to the birth weight by three weeks of age. If this does not occur, a full clinical assessment is required along with a feeding assessment. It is vital that support is given to the mother regarding breastfeeding, or feeding with infant formula or a combination of both. ASSESSMENT OF FALTERING GROWTH
Normally in the UK, an assessment of growth is made using the UK WHO growth charts advocated by the Royal College of Paediatrics and Child Health (RCPCH).5 The RCPCH provides charts and information for healthcare professionals and information is also provided for other visitors to their website, such as parents. www.NHDmag.com February 2019 - Issue 141
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PAEDIATRIC The UK WHO growth charts are based on WHO Child Growth Standards, and describe the optimal growth with regards weight and height for healthy breastfed children and allow both weight and height to be plotted on the charts. There are charts for 0-4 years designed to be used for preschool infants and toddlers (boys and girls), requiring plotting of growth data in primary or secondary care up to age four. The charts are also suitable for moderately preterm infants (32-36 weeks gestation) and include a BMI centile lookup and an adult height predictor. There are additional charts available for boys and girls from aged two to 18. Other charts are available for children who need close monitoring (up to 20 years) and children with Downâ&#x20AC;&#x2122;s syndrome. The centile lines on the charts have been derived from extensive data on infants and children and the lines show how one child compares with other children of the same age and sex. Any weights and heights that are positioned within the centile lines are considered to be in the normal range. The centile lines start from two weeks of age due to the weight fluctuations described after birth. The usage of the growth charts is central to the assessment of faltering growth and generally for infants of a normal birthweight, a fall of two or more centile spaces is considered as indicative of faltering growth.
a full clinical assessment is required to exclude issues such as coeliac disease, plus a detailed feeding and eating history with possible observations of this. Support for the parents is required to provide a realistic management plan with goals. For babies, supplementation of breast feeds with an infant formula may be required, or a change of formula to provide a more energy-dense feed may be provided. An alternative formula may be highlighted too, for any child established as having an allergy or intolerance. Adequate time for feeds needs to be encouraged. For older children, encouraging them to feed themselves and having positive mealtimes where families eat together on a regular basis, can be helpful. A regular meal pattern and snacks needs to be established. Regular monitoring is required and NICE advises daily, if less than a month old, weekly for those between one and six months of age, fortnightly for those 6- 12 months of age and then monthly thereafter. For those babies and children who do not improve, further investigations and support are required. Usually, such support is from a multidisciplinary team, which includes a dietitian.
GUIDANCE AND RECOMMENDATIONS
Registered dietitians can play a key role in the assessment and management of faltering growth, whether it be directly with a child, their parents and carers, or by providing support, training and to other healthcare professionals. Paediatric dietitians will have undertaken significant training in the management of faltering growth and are invaluable in providing information in very specialised areas like suitable infant formulae and should be able to advise GPs and community nurses about this. They should also be able to provide expert input into any documents and policies covering the subject. Paediatric dietitians belonging to the Paediatric Specialist Group of the BDA are able to keep up to date on related topics via this specialist network.9 Dietitians working in the community settings with infants and children should be aware of faltering growth and how it is assessed in order to provide a basis of support to families.
The NICE Guidance on Faltering Growth6 gives clear information and the different assessments to be used depending on the birthweight of the baby. For example: â&#x20AC;˘ a fall across one or more weight centile spaces if birthweight was below the 9th centile; â&#x20AC;˘ a fall across three or more centile spaces if birthweight was above the 91st centile. Often hospitals and hospital Trusts produce local guidelines for the establishment, investigation and management of faltering growth, which are published on hospital websites for the use of not just NHS staff, but also parents and others including nursery staff involved in the care of children.7 MANAGEMENT OF FALTERING GROWTH
Unless a child is very ill, normally faltering growth is managed in the community. Initially, 20
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DIETETIC INVOLVEMENT
This material is for healthcare professionals only.
DO MORE THAN JUST MANAGE COW’S MILK ALLERGY: HELP GIVE HER THE ABILITY TO ENJOY MILK SOONER1† ONLY‡ NUTRAMIGEN WITH LGG® CAN
TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY
† ‡
Versus an eHCF without LGG® or formulas based on soy or amino acids. The only cow’s milk-based formula.
Reference: 1. Canani RB et al. J Pediatr 2013;163:771–777. Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. Date of preparation: September 2018 UK/NUT/18/0060i
CONDITIONS & DISORDERS
ORTHOREXIA: AN EATING DISORDER OF THE MODERN AGE? The increasing trend for ‘eating clean’ can bring with it ‘unhealthy’ behaviours that in turn can lead to orthorexia nervosa, an eating disorder that is worryingly on the rise. Alice Fletcher Registered Dietitian within the NHS Countess of Chester NHS Foundation Trust (Community Dietitian) Alice has been a registered dietitian for four years working within NHS Community based teams. She is passionate about evidencebased nutrition and dispelling diet myths. Alice blogs about food and nutrition in her spare time at nutritionin wonderland.com.
REFERENCES Please visit the Subscriber zone at NHDmag.com
This article has been reviewed by Paul Jones, Specialist Dietitian, West Cheshire and Wirral CAMHS Eating Disorder Services and Eloise du Luart, a professional triathlete who has recovered from orthorexia.
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Is there any greater pleasure than biting into some hot salty buttered toast, or indulging in a warm scone with sumptuous clotted cream and strawberry jam with friends, knowing that it won’t harm you in the short term and such taste sensations are all part of a balanced diet? Does the thought of this fill you with horror? Does a green smoothie with a list as long as your arm of organic exotic ingredients like bee pollen sound much more inviting? It is a disproportionate view of the power of foods that can become an issue with orthorexia. We know that the occasional scone isn’t going to give us cancer, turn our blood to acid or make our gut ‘leak’, but those displaying symptoms of orthorexia no longer have a sense of proportion and can become so obsessed with food for health that they become paradoxically less healthy. Orthorexia has 137,000 tagged posts on Instagram, many from people recognising that their quest for health has become unhealthy. This number has doubled in three years since I last took note of it. But what exactly is orthorexia?
was first defined in 1997 by Californian doctor Steven Bratman (read more about it on his comprehensive website: www.orthorexia.com).1 Orthorexia refers to an unhealthy obsession with eating ‘pure’ food. Food considered ‘pure’ or ‘impure’ can vary from person to person. This doesn’t mean that anyone who subscribes to a healthy eating plan or diet is suffering from orthorexia. As with other eating disorders, the eating behaviour involved (‘healthy’ or ‘clean’ eating in this case) is used to cope with negative thoughts and feelings, or to feel in control. Someone using food in this way might feel extremely anxious or guilty if they eat food that they feel is unhealthy. It can also cause physical problems, because someone’s beliefs about what is healthy may lead to them cutting out essential nutrients or whole food groups. Another thing of note is that unlike other eating disorders, those displaying orthorexic tendencies may flaunt these beliefs publicly, social media (particularly Instagram) may be used for this purpose.
ORTHOREXIA NERVOSA
Diagnosis Although not formally recognised in the Diagnostic and Statistical Manual,
Orthorexia nervosa misleadingly translates to ‘correct/right [eating]’. It Table 1: Orthorexia buzzwords Clean
Detox
Healing
Unprocessed
Wholesome
Cleanse
Chemical free
Dairy free
Control
Purity
Organic
Gluten free
Raw
Innocent
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This material is for healthcare professionals only.
DO MORE THAN JUST MANAGE COW’S MILK ALLERGY: HELP GIVE HER THE ABILITY TO PROTECT HERSELF FROM FUTURE ALLERGIC MANIFESTATIONS1† ONLY NUTRAMIGEN WITH LGG® CAN
TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY
†
Versus Nutramigen without LGG®.
Reference: 1. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913. Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. Date of preparation: September 2018 UK/NUT/18/0060i
CONDITIONS & DISORDERS Table 2: The Bratman Orthorexia Self-Test1 If you are a healthy-diet enthusiast and you answer “yes” to any of the following questions, you may be developing orthorexia nervosa: (1) I spend so much of my life thinking about, choosing and preparing healthy food that it interferes with other dimensions of my life, such as love, creativity, family, friendship, work and school. (2) When I eat any food that I regard to be unhealthy, I feel anxious, guilty, impure, unclean and/or defiled; even to be near such foods disturbs me, and I feel judgmental of others who eat such foods. (3) My personal sense of peace, happiness, joy, safety and self-esteem is excessively dependent on the purity and rightness of what I eat. (4) Sometimes I would like to relax my self-imposed ‘good food’ rules for a special occasion, such as a wedding or a meal with family or friends, but I find that I cannot. (Note: If you have a medical condition in which it is unsafe for you to make ANY exception to your diet, then this item does not apply). (5) Over time, I have steadily eliminated more foods and expanded my list of food rules in an attempt to maintain or enhance health benefits; sometimes, I may take an existing food theory and add to it with beliefs of my own. (6) Following my theory of healthy eating has caused me to lose more weight than most people would say is good for me or has caused other signs of malnutrition such as hair loss, loss of menstruation or skin problems.
awareness about orthorexia is on the rise.4 Work has been carried out to develop a validated screening tool for the disorder (ORTHO-15), but this is not being used at present in the UK.2 However, it soon may come under the diagnosis bracket of ‘eating disorder not otherwise specified (EDNOS)’.3 Incidence The exact incidence of orthorexia remains difficult to quantify due to it not being a recognised standalone diagnosis, but its behavioural pattern is frequently observed by eating disorder specialists.3 Orthorexia may also go hand in hand with compulsive over exercising/exercise addiction, although evidence showing this is varied. As with anorexia, orthorexia is thought to be more common in women, but men may also be affected.1 Dr Bratman has developed a self-test to quickly see whether an individual’s healthy eating routine could have crossed the line into the realm of disordered eating, available on his website1 (see Table 2). FURTHER SIGNS, SYMPTOMS AND WARNING SIGNS OF ORTHOREXIA
It can be difficult to pinpoint when concern over the healthfulness of someone’s diet and behaviour has truly become a problem. This list is not exhaustive, but gives further insight into 24
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behavioural, physiological and psychological symptoms: • An increase in concern about the health of ingredients. • Spending considerable time scrutinising the source of foods, for example: - Have vegetables been exposed to pesticides? - Has nutritional content been lost during cooking? - Have artificial flavourings or preservatives been added? - Does food contain plastic-derived carcinogenic compounds? - Do the labels provide enough information to judge the quality of specific ingredients? • Cutting out an increasing number of food groups (all sugar, all carbs, dairy, meat, then all animal products); this fixation is primarily prompted by a desire to maximise physical health and wellbeing, rather than religious beliefs, concerns for sustainable agriculture, environmental protection, or animal welfare. • An inability to eat anything, but a narrow group of foods that are deemed ‘healthy’ or ‘pure’. • An unusual interest in the health of what others are eating. • Spending a considerable amount of time thinking about what food might be served at upcoming events and feeling anxious about it.
CASE STUDY EXAMPLE Unlike the eating disorder anorexia nervosa, where a sufferer may concern themselves with amounts of foods, orthorexia is about the health properties of foods. In February this year, Eloise du Luart (a professional triathlete who has recovered from both anorexia and orthorexia) spoke with the BBC about her experiences of orthorexia during her adult life.5 Eloise was diagnosed with anorexia as a teenager, but when she went to University, she thought that ‘clean eating’ had saved her. Eloise cut out major food groups and bought into (often expensive) foods that offered health-giving properties. Her breakfast would consist of ‘proats’ (protein oats), something we see all over Instagram, the contents of which included the addition of eight further ‘health’ ingredients: vegan protein powder, maca powder, bee pollen, baobab powder, chia seeds, raw cacao, almond butter and sugar-free chocolate. This would be presented beautifully and Eloise admits would often be cold by the time she ate it after taking photos of it for Instagram. She recognised that her lifestyle had become more of a problem than a cure when she fractured her back and was told that her bones had become brittle from malnutrition and overtraining. She sought help and has since recovered with professional support, including from the Performance and Eating Disorder Specialist Dietitian Renee McGregor (Twitter handle: @mcgregor_renee). When Eloise looks back on her experience with orthorexia, she reflects that she can “see the control and the obsession”. She reports that at the time she thought she was ‘detoxing’ her body.
• Showing high levels of distress when ‘safe’ or ‘healthy’ foods aren’t available. • Obsessive following of food and ‘healthy lifestyle’ blogs on Twitter and Instagram. • Not attending social events with friends and family due to concerns over what foods will be available (though this concern may be hidden). • Compensative behaviour (most commonly excessive exercise) if eating something considered to be ‘unclean’ may occur. • Body image concerns may or may not be present. • Micronutrient deficiencies, lack of menstruation in women and an underweight body mass index may or may not be present. ORTHOREXIA VERSUS CLEAN EATING
People who have suffered from orthorexia have reported the use of a restrictive diet to aid recovery from another diagnosed (or self diagnosed) illness (such as chronic fatigue syndrome), as having triggered orthorexia.1 The health blogger and café owner Ella Woodward (aka ‘Deliciously Ella’) does not herself have orthorexia, but she has famously documented her recovery from postural orthostatic tachycardia syndrome (POTS) through a diet free from grain (and gluten), dairy, refined sugar and additives. Whilst Ella has received much media attention,6
she has been faced with a backlash for promoting the ‘clean eating’ movement, which she refuted in an interview with Dr Giles Yeo on BBC TV’s Horizon, which aired in January 2017, titled Clean Eating - The Dirty Truth.7 Ella has since distanced herself from clean eating, instead focusing on a plant-based dietary approach for health. Adopting healthy eating patterns like Ella’s, is not orthorexia. An idea of ‘healthy eating’ may be conventional or unconventional, extreme, sensible, or completely bizarre, but regardless of this, that person does not necessarily have orthorexia. They are simply adhering to a style of diet. The term ‘orthorexia’ only applies when an eating disorder develops around that diet theory and it begins seriously affecting quality of life. Dr Bratman notes that the more restrictive a diet, the more likely it is to set off the psychological factors that lead to an eating disorder. ‘Clean eating’, which at its core involves wholefoods in their most natural state and avoiding processed foods such as refined sugar, is unlikely to lead to orthorexia. He notes that ‘raw foods veganism’ is on the other extreme and has a high orthorexic potential. This is a challenging diet to manage safely, and many people who will ultimately develop orthorexia have followed a raw vegan diet. Nonetheless, there are many people who adopt the raw-food vegan lifestyle and do not become orthorexic, so they are not intrinsically linked.1 www.NHDmag.com February 2019 - Issue 141
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CONDITIONS & DISORDERS Figure 1: Unique and shared features of orthorexia, anorexia and obsessive-compulsive disorder3 Orthorexia • Focus on food quality • Unrealistic food beliefs • Desire to maximise health • Flaunt behaviours
• Limited insight • Intrusive thoughts • Guilt over food • Ritualised food transgressions preparation • Perfectionism • Ego-syntonic • Focus on • Cognitive rigidity thoughts contamination • Trait anxiety • Impaired working memory • Impaired functioning OCD Anorexia • Poor external • Obsessions and • Focus on food quality monitoring compulsions may • Fear of obesity; extend beyond food disturbed body image • Secretive about • Realises that behaviours • Drive for thinness; behaviours are excessive/ excessive exercising • Depressed mood unreasonable • Ego-dystonic thoughts
ORTHOREXIA, OBSESSIVE COMPULSIVE DISORDER AND ANOREXIA
Orthorexia bears some similarities to anorexia and someone who has symptoms of orthorexia might be diagnosed with anorexia if they fit with those symptoms as well. Eating disorders that can’t be diagnosed as anorexia, bulimia, or binge eating disorder might be diagnosed as ‘other specified feeding or eating disorder’ (OSFED). The Venn diagram (Figure 1) shows how they are linked. SOCIAL MEDIA: IS IT A CONTRIBUTORY FACTOR?
‘Dieting’ is out and ‘wellness’ is in. Language around weight, body image and health is changing. Social media is packed with people declaring they are “strong”, not skinny, that they are “getting lean, eating clean” and turning to plant-based foods. Instagram is filled with tanned, lean, beautiful people eating sumptuous, exquisite plates of foods akin to works of art. Such people often manage to cram in and document two hours of exercise each day (without breaking a sweat, or instead 26
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sweating glitter), make three meals worth of organic gluten-free, dairy-free, grain-free, raw, vegan, (pleasure-free?) food for their equally beautiful family, work full-time and fly to the moon and back on a unicorn (well maybe not that part). Could the sheer volume of such influential seemingly perfect people, often recommending ‘detox’ products and special powders and pastes be increasing the incidence of those adopting very restrictive diets under the guise of health? That question is a tricky one to answer and, as mentioned earlier, following an extreme diet does not immediately mean that you develop orthorexia. Photographing beautiful food does not mean you necessarily have an eating disorder. However, the sheer volume of perfect gorgeous plates of food cooked by perfect bodies available to us at the touch of a button is certainly a huge change to the social landscape comparative to only 10 years ago. Whether social media could be defined as a causative factor, or simply enables orthorexic behaviour, is something tricky to detangle.
CLINICAL
BOLUS FEEDING
Bolus feeding is a method of enteral feeding, with continuous feeding via a pump being the alternative. This article aims to review the advantages and disadvantages of bolus feeding and its practical aspects. Bolus feeding is thought to be a preferable method of feeding in certain patient groups, such as head and neck cancer. Ultimately, it is up to the patient to choose which method of feed administration they would like and for the dietitian to educate on both bolus and continuous feeding, so that an informed decision can be made by the patient. Many of my dietetic colleagues and I are of the opinion that bolus feeding is more prevalent as a method of enteral feeding than it was 10 years ago. A 2016 survey showed that one third of patients receiving home enteral tube feeding were receiving part or all of their nutrition via bolus feeding.1 Following NICE (2006) guidance,2 patients fed into the stomach should be considered for continuous pump feeding or bolus feeding based on patient preference, convenience and drug administration. From experience, other factors should also be considered to determine which method of feeding is best. These include social circumstances, level of dependence, mobility and dexterity and gastrointestinal tolerance. It is the dietitian’s role to explain to the patient what each method of feeding entails, inform the patient of what is perceived to be the pros/ cons of each method of feeding and support the patient in their choice of method.
Louise Edwards Community Team Leader/Specialist Dietitian
If you were to conduct a literature search for ‘bolus feeding’ you would find very little evidence to support dietetic recommendations. Individual dietitian’s and dietetic departments experience with bolus feeding is generally what drives the recommendations made in regards to this method of feeding. In 2017, Nutricia Ltd launched a practical guide to ‘Bolus Feeding in Adults’3 aiming to define what bolus feeding is and to provide practical guidance to healthcare professionals involved in the enteral feeding of individuals. The guide is supported by BAPEN, the BDA, the British Pharmaceutical Nutrition Group (BPNG) and the National Nurses Nutrition Group (NNNG). This practical guide defines bolus feeding as: ‘The administration of feed through an enteral feeding tube as a series of smaller volume feeds given at regular intervals. A typical bolus is 200-250ml, but individual patients may tolerate more than this. This can be delivered with an enteral syringe or bolus set using a plunger, gravity, or a feeding pump.’3 Bolus feeding can involve the use of a ‘ready to hang’ feed bottle that is given at regular intervals throughout the day, but
Louise is a Specialist Dietitian working at the Central Cheshire Integrated Care Partnership (CCICP).
REFERENCES Please visit the Subscriber zone at NHDmag.com
With thanks to Kirsty Capper, Home Enteral Tube Feeding Dietitian, for sharing her dietetic experience.
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More in tune with patientsâ&#x20AC;&#x2122; lives A feed delivered the way you choose Bolus or Oral
Nutrison Energy Multi Fibre Vanilla 200ml Supports convenience and patient mobility when bolus feeding. Kcal Protein
308 12 g Fibre
4.4 g PER 200ML
This information is intended for healthcare professionals only. Nutrison Energy Multi Fibre Vanilla is a Food for Special Medical Purposes for the dietary management of disease related malnutrition and must be used under medical supervision.
Nutrison Energy Multi Fibre Vanilla 1.5 kcal/ml Right patient, right product, right outcomes
https://www.nutriciahcp.com/adult/products/Nutrison_Energy_Multi_Fibre_Vanilla/ Date of preparation: 01/19
CLINICAL Table 1: Advantages and disadvantages of bolus feeding Advantages
Disadvantages
Reduced amount of time of feeding.
A large volume bolus in a short time frame may not be well tolerated by the patient.
Flexibility regarding when feeds are given can mimic a ‘normal’ eating pattern and give patients increased opportunity to do activities/therapy sessions.
A level of dexterity and strength is required to administer the bolus feed.
Less equipment if syringe/gravity fed.
Potential for infection with the use of ‘open’ feeds.
Could be considered simpler to administer.
If bolus feeding is to be completed by a carer/family etc, length of visit needs to be for the duration of the feed and frequent for each bolus.
Timing of feed administration can be arranged around care calls, when carers/family are available (if patient dependent).
If being administered via a nasogastric tube (NGT), it’s time consuming due to the requirement to confirm NGT position for each bolus feed.
Safer method of feeding if patient is unable to maintain positioning for a significant period of time.
Required to store a large number of oral nutritional supplements (ONS).
Useful as a ‘top up’ for patients whose oral intake may be insufficient to meet nutritional requirements.
It can be difficult to meet fluid requirements for dependent patients when care is only available for feed boluses.
Regular bolus feeds may reduce hunger compared to a fixed time period on continuous pump feeding.
Fast administration of feeds is not well tolerated by everyone.
Easier to facilitate transition to oral intake (if appropriate).
Not suitable for post pyloric feeding.
more commonly it is sip feeds that are used for the bolus. Bolus feeding should not be routinely used for post pyloric feeding, since guidelines have discussed that bolus delivery into the jejunum can cause a ‘dumping’ type syndrome effect.6 Continuous pump feeding refers to nutrition being administered via an electronic pump at a specific rate, often using a larger volume of feed over a significant time frame (ie, over 10 hours). In order to assist my patients in making well informed decisions as to which method of feeding they would like, I highlight what could be perceived to be the advantages and disadvantages of each method. Table 1 lists these for bolus feeding, but it is by no means exhaustive. However, you may find certain points in the Table that your patient would view as important to their quality of life. PATIENT GROUPS
You may consider patient groups for which bolus feeding is seen to be preferable to continuous
pump feeding, such as for head and neck cancer patients. Around one quarter of adults receiving home enteral tube feeding (HETF) registered with the British Artificial Nutrition Survey (BANS) had a diagnosis of cancer, with over 80% having head and neck cancer.4 The BANS report 2018 highlighted that this patient group is generally relatively independent and active, therefore, a feeding regime that fits in with an active lifestyle is required. Bolus feeding is often used more frequently in this patient group, particularly in those receiving outpatient treatments, those who work during oncological treatment, and for those who wish to have more flexibility with feeding.7 As oral dietary intake may decline as a side effect of oncology treatment, bolus feeding can be highly appropriate, by administering ONS via a feeding tube that can be increased in frequency to support nutritional requirements. There is also flexibility in finding the time to administer bolus feeds around outpatient appointments. www.NHDmag.com February 2019 - Issue 141
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CLINICAL Table 2: The methods of bolus feeding - considerations Syringe plunger
Gravity
Pump
More control over flow rate.
Useful if not tolerating ‘syringe plunger’ method as slower flow.
Useful when a large volume bolus is indicated.
Requires a level of dexterity.
Requires a level of dexterity.
Dexterity required for setting up, giving set and feeding pump.
Requires a level of strength.
Requires a level of strength.
Useful when a specific feeding rate is indicated.
Can be rather messy.
Bolus feeding may also be a preferable feeding option for post stroke patients undergoing rehabilitation therapy. This is due to the flexibility of administering boluses pre and post therapy sessions. From experience, bolus feeding is also desirable over continuous pump feeding in individuals who struggle to maintain a safe feeding position (torso at >30 degree angle) for a significant period of time. Bolus feeding of a high calorie, small volume ONS via a feeding tube enables a substantial amount of calories to be administered over a short time frame. As long as a safe feeding position is maintained during this bolus and at least 30 minutes after significant nutrition can be administered safely. This repeated several times over the day (as per dietetic recommendations) ensures that the patient’s nutritional requirements are met and the patient’s safety has been considered in regards to feeding with poor positioning. A randomised control trial (RCT) looking at whether continuous pump feeding over bolus feeding reduced the incidence of pneumonia in nasogastric fed patients found no statistical difference.5 From my experience in the acute setting, continuous pump feeding is more commonly initiated as the method of enteral tube feeding since nursing staff may find it easier to set up and administer. With a bolus feeding regime there is the possibility that a feed bolus may be missed by a nurse if they are busy, resulting in the patient being under fed. If the patient is dependent on nursing staff administering the feed via their enteral feeding tube, bolus feeding could be interpreted to require more nursing time and, therefore, be more labour intensive. Bolus feeding can be conducted using three different methods: 30
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1 Bolus by syringe plunger - when the syringe is filled with feed and the syringe plunger is pushed to administer the feed. 2 Bolus by gravity - when the syringe is filled with feed with the plunger removed, the syringe is held upwards with gravity promoting the feed down the tube. 3 Bolus by pump - when a giving set and pump is used to administer feed at a specific rate. Table 2 summarises some considerations of each method. CONCLUSION
Whether a patient decides to bolus feed or be fed continuously using a pump, your role as a dietitian is to support them in making the right decision for them, assuming they have the capacity to do so. Discussing the advantages and disadvantages is paramount to ensure that the patient and their family/carers can make an informed decision. For the majority of patients who are being enterally tube fed, the aim is to try and improve their quality of life to whatever that means for the patient. Regular reviews of the patient and their method of feeding is recommended to ensure that it is not impacting on their quality of life, for example, it may be taking up too much time and the patient may be unable to leave the house. The products we use to bolus feed a patient vary from ready-to-hang formulas to ONS. In the current market, this may begin to shift as companies focus more on providing a suitable bolus feed product more nutritionally complete than using ONS. This in turn may impact the decision-making process when considering bolus feeding.
AN INTRODUCTION TO MINDFULNESS
SKILLS & LEARNING
Mindfulness has become a big buzz word over the past few years. But what does it mean and how do we become mindful eaters? Mindfulness is a mind-body practice which describes the human ability to be fully present and in the moment.1 Mindfulness is about paying attention but not overly reacting to automatic thoughts and behaviour patterns, and managing them more effectively through techniques such as meditation, breathing and yoga.2 Mindfulness is based on ancient Zen Buddhist meditation techniques; however, this doesnâ&#x20AC;&#x2122;t mean that you need to be religious or spiritual to practice mindfulness. Over the years, various types of mindfulness interventions have emerged, with the most common types being: mindfulness-based stress reduction (MBSR), mindfulnessbased cognitive therapy (MCBT), dialectical behaviours therapy (DBT), acceptance and commitment therapy (ACT) and mindfulness-based relapse prevention (MBRP). Without a doubt, MBSR and MBCT are the most extensively researched mindfulness interventions.3 MBSR was developed by Dr Jon Kabat-Zinn at the University of Massachusetts in the 1970s, following the success of a stress reduction programme for people with chronic illnesses. MBSR involves three main elements: the body scan (mindful body perception), gentle yoga exercises and the traditional sitting meditation.4 MBCT is based upon MBSR; however, it integrates the principles of mindfulness with cognitive therapies. It was originally developed as a relapseprevention treatment for adults with major depressive disorder, and the cognitive element focuses on better acceptance and compliance of the
present self. The goal of MBCT is to disrupt negative automatic thought processes and to not overreact to incoming stimuli, instead focusing on reflection, acceptance and observation.5 Westernised conceptualisation of mindfulness has become an innovative psychological intervention for physical and mental health conditions,2 and much of the research on mindfulness has focused on the clinical efficacy of mindfulness-based interventions.6 HEALTH BENEFITS OF MINDFULNESS
The research base for mindfulness and health and wellbeing is constantly evolving. Methodologically rigorous randomised control trials have demonstrated that mindfulness-based interventions improve outcomes in multiple domains, including chronic pain, depression relapse, stress and anxiety.2 NICE guidelines currently recommend mindfulness-based cognitive therapy for people who are currently well but have experienced three or more previous episodes of depression. NICE recommend that MBCT should be delivered in groups of eight to 15 participants and consist of weekly twohour meetings over eight weeks.7 Whilst there is good evidence to suggest that MBCT is associated with positive outcomes in prevention of depressive relapse or recurrence, a large randomised control trial found no evidence that mindfulness-based therapies were superior to maintenance antidepressant treatment.8 This suggests that mindfulness-based therapies shouldnâ&#x20AC;&#x2122;t be used as standalone treatments. Furthermore, NICE does not routinely recommend mindfulness-
Harriet Smith RD Freelance Dietitian and Health Writer Harriet is Founder of Surrey Dietitian providing private dietetic consultations and consultancy services, offering evidence-based nutritional advice, backed up by the latest research on food, health and disease. Harriet has written for national, consumer and industry media. www.surrey dietitian.co.uk @SurreyDietitian
REFERENCES Please visit the Subscriber zone at NHDmag.com
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SKILLS & LEARNING based interventions or supportive therapy to treat social anxiety disorder. Many of the studies investigating mindfulnessbased interventions in chronic conditions are either small or have methodological weaknesses. One small randomised trial of 33 fibromyalgia patients found that mindfulness-based interventions significantly reduced the impact of the illness and depressive symptoms after treatment.9 However, a larger randomised trial in 133 women did not support the efficacy of MBSR in fibromyalgia and concluded that further high-quality research is required.10 However, participation in a MBSR programme may help people to cope better with symptoms of chronic disease, and improve their well-being and quality of life.11 MINDFULNESS AND DIET
Much of the research on mindfulness and diet focuses on mindfulness-based interventions in disordered eating. For example, a systematic review of 14 studies found that mindfulness meditation effectively decreased binge eating and emotional eating in populations engaging with this behaviour. Interestingly, they concluded that the quality of evidence of mindfulnessbased interventions on weight isn’t as strong and warrants further research.12 However, there is very little evidence about the mechanisms of mindfulness and how this influences eating behaviours and diet. Additionally, there is very little evidence about the most effective types of mindfulness interventions, although MBCT and MBSR seem to be the most researched interventions.13 There is a lack of evidence looking at the effects of mindfulness on weight loss, with many studies concluding that randomised control studies are needed.14 A systematic review of 19 studies found that six of the eight randomised control trials reviewed reported significant weight loss in the intervention group (those who received a mindfulness-based intervention) compared with the control group. However, none of these studies reported a relationship between changes in mindfulness and weight loss. This means that we don’t know whether the weight loss seen in the mindfulness group was due to the mindfulness intervention itself or other factors, which is a methodological weakness of this study.13 32
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A literature review of 21 papers found that 86% of the reviewed studies reported targeted improvements in eating behaviours amongst obese participants (including binge eating, emotional eating and external eating) following a variety of mindfulness-based interventions. The authors concluded that there is emerging evidence to support the use of mindfulnessbased interventions in positively changing obesity-related eating behaviours.15 More recently, a systematic review and metaanalysis reviewed 19 studies, looking at the effects of mindfulness on weight loss, eating behaviours, psychological outcomes and mindfulness. Overall, they found that mindfulness-based interventions were associated with small-to-moderate effects on weight loss, with an average loss of 7lbs at follow-up (four months post intervention). There were also some significant reductions in eating behaviours in the mindfulness group, such as a reduction in binge eating.16 There were some major limitations to this study, including small sample sizes, unrepresentative samples (mainly women), not controlling for confounders and a lack of data on long-term weight loss maintenance. Therefore, we can’t say for sure whether mindfulness helps with weight loss; however, it may be something that people want to try. INCORPORATING MINDFULNESS INTO DAILY LIFE
Mindfulness can be practiced on your own, in a group setting, or one-to-one with a trained mindfulness coach. There is an abundance of books, websites, podcasts and apps available, which can be used for self-directed practice at home. It can be as simple as paying attention to your breath, focusing on the speed, sensations and patterns of your breathing, or walking through nature and taking in the sights and sounds of your surroundings. Mindful eating is about paying attention to the eating experience, being fully present and not getting caught up in any thoughts or worries at the back of your mind. It can be as simple as switching off your phone at meals and recognising the different tastes, textures and colours of foods.
Mindful eating is about paying attention to the eating experience, being fully present and not getting caught up in any thoughts or worries at the back of your mind.
Characteristics of mindful eating include: • eating more slowly, acknowledging feelings and sensations (ie, hunger) and stopping eating before you are uncomfortably full; • enjoying foods that you want to eat and savouring the eating experience; • responding to body signals and eating when your body tells you to (ie, when you feel hungry, when your stomach grumbles, or when you feel tired/dizzy); • focusing on the present moment – switch off background distractions (ie, screens/ music) – and remaining open to how things unfold rather than focusing on preconceived conceptions about how things should turn out; • being fully present – recognising the different sensations whilst eating (smells/ textures/colours of foods), enjoying the company of others whilst eating and trying to avoid eating on to go; • compassion – being gentle and kind on yourself, not judging or punishing yourself
after eating and recognising that every food can have a role in a healthy and balanced diet. SUMMARY
Despite many uncertainties and flaws in the literature, mindfulness has been shown to have benefits for mental wellbeing, which is reflected in the NICE guidelines. As with many nutrition topics, we need more high-quality evidence before we conclude whether mindfulness is likely to benefit other aspects of our diet and eating behaviours. However, there doesn’t appear to be any harm in applying the key components of mindfulness to everyday life and eating. Many of the components of mindful eating (such as eating more slowly and savouring the eating experience) are things we should all be trying to do at mealtimes. What's more, there is some preliminary evidence to suggest that mindful eating, even in the absence of weight changes, can be beneficial in patients with disordered eating.
USEFUL RESOURCES FOR MINDFULNESS • Free apps such as Calm or Headspace, or paid-for apps such as Buddhify • Mind – free mindfulness exercises and tips from www.mind.org.uk/ • Be Mindful - part of the Mental Health Foundation charity: www.mentalhealth.org.uk/. This is a four-week online mindfulness course developed by qualified teachers: https://bemindful.co.uk. It’s listed in the NHS Digital Library at https://apps.beta.nhs.uk • Breathworks offers mindfulness courses to manage pain, stress and illness: www.breathworksmindfulness.org.uk • The book Mindfulness: A practical guide to finding peace in a frantic world by Prof Mark Williams and Dr Danny Penman • Bruce Langford Podcasts 10% Happier, The Self Help & Mindfulness Mode: http://mindfulnessmode.com
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YOUR ESSENTIAL RESOURCE
IMD WATCH
THE COSTS OF A SPECIAL DIET In a health service concerned with limited resources, cost effectiveness is a consideration, as well as clinical effectiveness. This article will consider ‘the critical requirements’ for a very low-protein diet in inherited metabolic disease (IMD), specifically highlighting the diet in PKU. This includes outlining why this investment is needed and why an understanding of the cost is required. There are a few inborn errors of metabolism for which treatment is a very low-protein diet supplemented with a protein substitute or replacement. PKU is one of these conditions. Patients are required to consume specialist prescription-only protein substitutes and low phenylalanine (Phe) foods. Treatment is lifelong.1,2 Women with PKU who are pregnant, or who are planning a pregnancy, need to take particular care to manage their condition, as high Phe levels can damage their unborn child. There are other IMDs for which a low-protein diet is indicated, such as homocystinuria (HCU), tyrosinemia and maple syrup urine disease (MSUD). Patients with IMDs on ultra-lowprotein diets are supervised and monitored by Specialist Centres across the UK, commissioned centrally.3 The specialist dietary products are prescription only, are not available commercially and are approved by the Advisory Committee on Borderline Substances (ACBS). Patients require a regular and consistent supply of a large number of prescribed products as part of the synthetic diet, otherwise metabolic control is compromised. There are an estimated 10,000 patients attending metabolic clinics. We do not know how many patients are on a very low-protein diet requiring prescribable products, but it is estimated that, in the UK, 2500 patients with PKU are on a diet and a further 60 to 70 new diagnoses of PKU occur every year.
The rationale of PKU treatment is to achieve strict blood control to prevent any brain damage or impairment in children4-7 and avoid the reduced life chances via reductions in IQ. When treatment is compromised, it is clear that children with PKU have lower IQs than their non-PKU siblings.8,9 Historically, the diet was thought necessary only for children, since the evidence base on PKU in adulthood was ‘work in progress’. The accumulated evidence is now clear that adults with uncontrolled blood Phe levels are compromised in their executive function, their mental health and their psychosocial outcomes.10-14 There is international agreement and recommendation that lifelong treatment is essential.1,2 PRESCRIPTIONS PART 1 - PROTEIN SUBSTITUTE USE IN PKU
Protein substitutes are the lynchpin of a very low Phe diet, as the patients’ protein/nitrogen and micronutrient requirements must be met.15,16 The products should be taken at least three times daily, every day of a patient’s life following diagnosis and, thus, a range of palatable products are essential.17,18 A reminder: the nutrients being substituted are macro as well as micronutrients, thus, daily doses of substitutes are high, eg, 80 tablets per day for a 55kg woman. There have been considerable efforts in the last 30 years to develop these products to aid optimum safety,
Suzanne Ford, Dietary Advisor to NSPKU Suzanne Ford is a Metabolic Dietitian working with Adults at North Bristol NHS Trust and also for the National Society of Phenylketonuria (NSPKU).
Professor Anita MacDonald, OBE Consultant Dietitian in IMD, Birmingham Children's Hospital One of the UK’s top paediatric dietitians, Anita’s specialism lies with inherited metabolic disorders.
REFERENCES Please visit the Subscriber zone at NHDmag.com
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IMD WATCH Table 1: Food portions that provide 1g of protein, ie, 1 exchange/50mg phenylalanine Cow’s milk
30mL
Jacket or boiled potatoes
80g
Single cream
40mL
Roast potatoes
55g
Double cream
60mL
Chips
45g
Yoghurt
20g
Broad beans
20g
Rice - boiled
45g
Peas (fresh, frozen and tinned)
25g
Rice - raw
15g
Spring greens (boiled)
35g
Table 2: Cost of low phenylalanine diet for an adult with PKU (calculated Dec 2018) Daily requirement 60g protein equivalent from protein substitute Based on the average cost of 3 brands
Cost per annum £11,617
Weekly requirement
Daily requirement 80g protein equivalent from protein substitute Based on the average cost of 3 brands
Cost per annum £15,489
Weekly requirement
114g low-protein bread per day (800g/week)
£416
114g low-protein bread per day (800g/week)
£416
500g low-protein flour per week
£364
500g low-protein flour per week
£364
400ml low-protein milk per day (14 cartons per week)
£927
400ml low-protein milk per day (14 cartons per week)
£927
250g pasta per week
£224
250g pasta per week
£224
1 pizza base per week
£224
1 pizza base per week
£224
£265
100g sausage mix/burger mix per week
£265
100g sausage mix/burger mix per week Total cost
£14,037
tolerance, efficacy and palatability. Most protein substitute products contain micronutrients and, more recently, have added docosahexaenoic acid - for use in pregnancy as well as infants and children.19 Finally, as well as reducing protein or micronutrient deficiencies, the protein substitutes provide protection (through provision of amino acids) against high blood Phe levels by reducing catabolism and promoting anabolism. Protein substitute range and product development A wide range of protein substitutes should be available for patients with IMDs such as PKU, as it is well established that patients struggle to fully adhere to protein substitutes due to their low palatability. A patient's age-related and clinical needs must be met, eg, infancy, weaning, childhood, pregnancy, both higher and lower calorie formulae subject to growth needs.20 Pre36
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Total cost
£17,909
prepared liquid protein substitutes and formulae have some clinical advantages to powders and there is a variety of different presentations available to patients.21,22 Protein substitute choices (for people with PKU) have recently expanded to include glycomacropeptide (GMP) powders and liquids. These are reported to have high levels of patient acceptability (reduced acidity compared to amino acids and a lower osmolarity, so reduced osmolar effects on the gut). However, in some areas, GPs and CCG exceptions panels have declined to support people with PKU by declining to fund GMP products to their patients, despite much clinical evidence to support them.29-31 Future development of better protein substitutes to improve acceptability and adherence is essential for better outcomes in PKU, as is the support of prescribers for these products.
Table 3: Cost of low phenylalanine diet for children with PKU (calculated Dec 2018) 3-year-old child weighing 14kg Daily requirement 40g protein equivalent from protein substitute* Based on the average cost of 2 brands
Cost per annum £8251
Weekly requirement
7-year-old child weighing 22kg Daily requirement 50g protein equivalent from protein substitute Based on the average cost of 2 brands
Cost per annum £9526
Weekly requirement
40g low-protein bread per day (280g/week)
£145
80g low-protein bread per day (560g/week)
£290
250g low-protein flour per week
£182
500g low-protein flour per week
£364
600ml low-protein milk per day (21 cartons per week)
£1391
400ml low-protein milk per day (14 cartons per week)
£927
125g pasta per week
£112
250g pasta per week
£224
0.5 pizza base per week
£112
1 pizza base per week
£224
50g sausage mix/burger mix per week
£133
100g sausage mix/burger mix per week
£265
Total cost
£10,326
Total cost
£11,820
* Protein substitute gels/pastes are used for children usually up to four years. These are more expensive because the demand for these is smaller than for liquid protein substitutes.
PRESCRIPTIONS PART 2 - LOW-PROTEIN PRODUCTS
Specialist low-protein products are needed to provide variety and bulk to children and adults, as their products are not available in supermarkets nor in health food as glutenfree products now are. If low-protein products are used insufficiently, then energy intake is compromised and endogenous Phe is released through catabolism, or the individual is hungry and is likely to eat higher protein food choices, resulting in loss of metabolic control. Scottish research (done before gluten-free food prescription was questioned), outlines the negative experiences and obstructions which people with PKU have experienced when attempting to access prescribable low-protein products.23 It is not uncommon for patients or parents to feel humiliated and frustrated by either the system or by staff within primary care and when no food is accessible, a hungry and uncontrolled patient is the result. Table 1 illustrates the level of restrictions involved in this diet – it is not possible for most patients to maintain metabolic control without prescribable foods,24 as hunger would be overwhelming. Most of the people with PKU
recently completing an NSPKU survey,25 were prescribed fewer than 10 PKU exchanges, or 10g protein, per day. An example of food providing 1g protein is listed in Table 1. Unlike diabetes, epilepsy or hypothyroidism, inborn errors of metabolism are not part of the medical exemptions for paying prescription charges. Many adults with PKU who are on diet use a prepayment certificate for their treatments (currently £104 for 12 months), though in Scotland and Wales, prescriptions are free. COST OF THE LOW-PROTEIN DIET TO THE NHS
The overall cost is in the region of £12,000£18,000 per year, with the overall cost varying subject to the age of the patient and their size, as protein substitutes are prescribed in a weight dependent manner. COST COMPARISON OF OTHER TREATMENTS FOR IMDS
As researchers develop pharmacological solutions for IMDs, it is important to compare cost effectiveness with each different treatment approach, so this is one reason for an accurate picture of the cost of dietary treatment. In the future, it is possible that enzyme chaperone, www.NHDmag.com February 2019 - Issue 141
37
TASTE
FOR YOURSELF
Book a free tasting session and discover the joy that our tasty, nutritious meals can bring to patient mealtimes. For your free session call
0800 066 3169 or visit wiltshirefarmfoods.com
OVER 300 DELICIOUS DISHES NUTRITIONAL EXPERTISE SPECIALIST DIET RANGES
IMD WATCH Table 4: Guideline low-protein product amounts per month (NSPKU 2017)26 Age of patient with PKU
Recommended maximum number of low-protein items to prescribe each month
4 months to 3 years
15 units
4-6 years
25 units
7-10 years
30 units
11-18 years
50 units
Adults
50 units
Pre-pregnancy/ pregnancy
50 units
Table 5: Prescribable low-protein food groups and units ACBS prescribable foods
Definition of one unit
Pasta
1 box (500g)
Bread/bread rolls
1 packet
Flour mix/cake mix
1 packet (500g)
Breakfast cereals
1 packet
Pasta snack pots
4 snack pots
Pizza bases
2 pizza bases
Sausage/burger mixes
4 sachets
Biscuits
1 packet (150g)
Energy supplements, eg, Vitabite and Chocotino
1 packet
Cakes
6 x 40g
Egg replacer
1 packet
Dessert mixes
6 sachet
Low-protein spreads
1 tub
enzyme substitution therapies, probiotics with enzymes and similar, could reduce or completely negate the need for dietary treatment. Price comparisons, therefore, may occur in the future so that the full economic impact of new treatments can be judged. At the time of writing, an enzyme chaperone molecule called sapropterin dihydrochloride, marketed as Kuvan, is under consideration for commissioning for PKU and this would be an alternative or an adjunct to dietary treatment of PKU in the UK.
WHAT ARE THE CURRENT PRESSURES?
On 28th November 2018, NHS England published Prescribing Gluten Free Foods in Primary Care: Guidance for CCGS,27 which changes the law about the obligations to patients with coeliac disease. There are similarities in the types of products, but there is one significant difference: if you are on a low-protein diet you cannot buy low-protein products in a supermarket. Primary care staff are likely to be more familiar with what gluten-free prescriptions are about, who they are for and the recent restrictions in gluten-free prescriptions than the existence of metabolic disorders and treatment with low-protein foods (and protein substitute) via primary care as outlined by NHS Specialist Commissioning guidelines, so difficulties are anticipated. Currently, time is taken up of NHS primary and tertiary care staff, as well as patient and carers in sorting out confusion about prescriptions in PKU and breaks in treatment do occur as outlined in interim results of a patient prescriptions registry.28 CONCLUSION
There are several challenges to ensure that patients with IMDs receive effective treatment delivered with continuity – this includes patients with PKU. At the time of writing, dietary treatment is the only treatment for many of these patients. Innovative ways could exist for better access to prescribable products for metabolic patients and there have already been small projects in the UK working on this, though not in metabolic disorders. However, all involved in the pathways of metabolic treatments need to appreciate both the costs involved and the necessity of treatment.
For NSPKU supporting documents, please visit www.nspku.org and click on leaflets to download, including: • Supporting Patients with PKU in the GP Surgery: A Guide for GP Administrative Staff • Information for Pharmacists • Prescription Guidelines Also: Follow NSPKU on Twitter @NSPKU www.NHDmag.com February 2019 - Issue 141
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CONDITIONS & DISORDERS
MALDIGESTION OR MALABSORPTION? THE DIFFERENCES EXPLAINED
Dr Mabel Blades Independent Freelance Dietitian and Nutritionist Mabel is a Registered Dietitian, a member of the BDA and NAGE, Food Counts, Older people Specialist Group and the Freelance Dietitians Group. All aspects of nutrition enthuse her and she is passionate about the provision of nutritional information to people in assisting their understanding of any diet.
REFERENCES Please visit the Subscriber zone at NHDmag.com
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The terms ‘maldigestion’ and ‘malabsorption’ are often used incorrectly and the terms are often used as alternatives for each other. Malabsorption is the term most commonly used, but maldigestion may be a more physiological description in some situations. This article provides an overview, with some suggested resources. On scanning various medical, nursing and nutritional dictionaries, it was found that only the term ‘malabsorption’ appeared, with the term ‘maldigestion’ not being covered. Thus, it is not surprising that maldigestion is not so well known. Dietitians can help advise about all types of diet in order to assist with both of these conditions. DIGESTION AND ABSORPTION
Digestion is the breakdown of complex compounds into the constituent smaller molecules, which can be absorbed by various areas of the digestive tract. In the body the breakdown is due to the production of digestive enzymes. The process may also occur in the food industry where chemicals (as well as enzymes) are used to achieve such results. Absorption is the process whereby the smaller molecules of the nutrients resulting from the process of digestion, pass through the wall of the digestive tract and into the blood or lymphatic fluids. While the two processes are physiologically different, they are interdependent, with no absorption being possible unless there is first the stage of digestion which enables absorption to occur. However, it appears that the term malabsorption has taken prominence over maldigestion. Most of the digestion and absorption occurs in the small intestine, but other parts of the digestive tract can also be involved.
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RESULTS OF MALDIGESTION AND MALABSORPTION
Both maldigestion and malabsorption result in some form of undernutrition of various nutrients, plus energy, as well as additional adverse consequences of unpleasant symptoms. The symptoms include diarrhoea, bloating, pain and discomfort, plus nutritional issues of undernutrition, like anaemia, osteoporosis, poor growth, fatigue and weight loss, to name but a few. EXAMPLES OF MALDIGESTION
Lactose intolerance For the digestion of lactose from milk, the enzyme lactase must be produced by the brush border of the small intestine. Lactose is the main sugar found in cow’s milk and when it’s not fully broken down and absorbed by the body it can ferment in the gut and lead to pain and bloating. In order for lactose to be absorbed, it needs to be broken down by a special enzyme called lactase. Lactase is usually found naturally in the gut, but some people have very little lactase production and, thus, do not have enough lactase to digest lactose properly. There are two types of lactose intolerance, primary and secondary. Primary intolerance is when the body just doesn’t produce sufficient lactase. Around 70% of the world’s population has this type of lactose intolerance. It is most commonly found in certain ethnic groups, especially Asian, African and
Both maldigestion and malabsorption result in some form of undernutrition of various nutrients, plus energy, as well as additional adverse consequences of unpleasant symptoms.
Hispanic people. This is because their traditional diets over the years have not contained much lactose, so their digestive systems have lost the ability to produce much lactase once they are weaned. Secondary intolerance is when the lining of the gut is damaged and temporarily doesnâ&#x20AC;&#x2122;t produce enough lactase. This can be caused by any condition that damages and irritates the gut, such as gastroenteritis. More serious conditions, such as Crohnâ&#x20AC;&#x2122;s disease, coeliac disease and alcoholism, can also cause a secondary intolerance. In the UK, most cases of lactose intolerance are secondary and are as a result of another illness or condition and many people after a bout of gastroenteritis find that they are unable to tolerate milk until the lining of the gut recovers. The BDA produces useful information on lactose intolerance, which includes helpful advice on suitable milks and foods.1 Sucrase-isomaltase deficiency As occurs with lactose, the digestion of disaccharides and some oligosaccharides is undertaken by a number of small intestinal brush border enzymes and other forms of maldigestion of disaccharides occur, which require dietetic advice. Sucrase-isomaltase deficiency is a very rare congenital condition (except in Greenland) that requires the exclusion of sucrose from the diet.
Deficiency of pancreatic enzymes The lack of pancreatic enzymes responsible for the digestion of protein fat and carbohydrate are seen in pancreatic disorders, with a resultant deficiency in absorption of nutrients. The genetic disorder cystic fibrosis causes a defect in both the lungs and the pancreas, with the latter affecting the production of pancreatic enzymes. Treatment normally involves the prescribing of pancreatic enzymes as supplements, plus an appropriate diet.2 EXAMPLE OF MALABSORPTION
Coeliac disease This is a well-known condition requiring the avoidance of gluten. It is an autoimmune condition where the body reacts to gliadin in gluten causing the wall of the small intestine to become inflamed and the villi to be flattened. The villi increase the surface area of the gut and enable the correct absorption of nutrients so that the reduction in villi causes a reduced absorption of nutrients. Many sufferers present with weight loss, anaemia and osteoporosis. It is not known why some people develop coeliac disease, but the risk is increased in those with an established family history of the condition. It is also considered that giving gluten to babies before three months of age is associated with the later development of coeliac disease. Type 1 diabetes, itself an autoimmune condition, www.NHDmag.com February 2019 - Issue 141
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CONDITIONS & DISORDERS is also associated with the increased likelihood of the development of coeliac disease. Diagnosis is by examining a blood test for antibodies to gluten and the diagnosis is confirmed by a biopsy. For the biopsy to show clear results, sufferers are required to resume consuming gluten. However, due to adverse symptoms, many people prefer to simply continue a gluten-free diet. Treatment is by a lifelong gluten-free diet which needs to be rigorously kept to. Today, there are many glutenfree foods available, plus restaurants and other venues are well aware of the need to provide gluten-free food. Food labels are required by law to show food allergens including gluten.3 Crohnâ&#x20AC;&#x2122;s disease This is one of the inflammatory bowel diseases and causes inflammation at any point in the length of the digestive tract, which results in malabsorption and diarrhoea, as well as pain and discomfort.4,5 Pernicious anaemia Like iron deficiency anaemia, this condition results in symptoms of tiredness and lethargy, but is due to a lack of vitamin B12 needed for the formation of red blood cells that transport oxygen around the body. Vitamin B12 is absorbed in the ileum which is the final part of the small intestine. The stomach secretes a protein called intrinsic factor which binds with the vitamin B12 and enables its absorption. The secretion
C
P
of intrinsic factor in the stomach ceases in some people as they get older due to an autoimmune condition which occurs often in women over the age of 60. Thus, vitamin B12 cannot be absorbed due to the lack of intrinsic factor and has to be provided by regular injections, usually given every three months.6 Short bowel syndrome Other forms of malabsorption include short bowel syndrome where the length of the small intestine is reduced so that the absorptive area is reduced. Some infants are born with this condition while other people develop it due to surgical removal of part of the small intestine after either an injury or illness. Such conditions require considerable nutritional support, including on occasions parenteral nutrition. BARIATRIC SURGERY
The surgical procedure called a Roux en Y Gastric Bypass is used as a method of managing morbid obesity. A small pouch is made from the top of the stomach and then connected to part of the small intestine. In doing so, the small size of the stomach means that people feel full quickly and that by attaching the stomach pouch to the ileum and thus bypassing the absorptive area, the upper part of the small intestine (duodenum) and, therefore, the nutrients are not so well absorbed and weight loss is promoted. Such procedures require lifelong supplementation with vitamins and minerals.
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eARTICLES Continuing professional development Click here to view our NHD CPD eARTICLES NHDmag.com 42
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F2F
FACE TO FACE Ursula meets: DR PAUL SACHER Paediatric Dietitian Co-founder of MEND (Mind, Exercise, Nutrition . . . Do it!): international child weight management programme Digital health and wellness expert
We met in a restaurant. It was a cold night and the little table candle was not doing much to help warm us. Our table was wobbly; it became a back and forth between us, tilting my way as I scribbled notes, or Paul’s way as he placed down his green tea. Paul is originally from South Africa, has travelled extensively and has lived in the UK for 23 years. His first degree was at the University of Cape Town - a BSc in Human Physiology, with a view to becoming a doctor. A single lecture on nutrition was such an inspiration, that Paul signed up to a newly launched twoyear postgraduate degree in Clinical Nutrition and Dietetics. To join various family members, he moved to Sydney in Australia. It took a while to get his South African dietetic qualification accredited, so he passed the time jobbing, including working as a hospital catering assistant, supervising the preparation of special diets. Then, in 1995, upon the siren call of friends, he went to London. A locum agency offered him a newly-funded paediatric dietetic post at Chase Farm Hospital. The post was made permanent and Paul was asked to stay, but declined based on excessive travel time. He next did a four-day paediatric post at the Whittington Hospital, matched with a one-day research post at the Royal Free Hospital. After a few years, he moved to another paediatric
Ursula meets amazing people who influence nutrition policies and practices in the UK. and management post at Ealing Hospital, where he also developed a specialism in children (and adults) with HIV. “Great Ormond Street (GOSH) is the most challenging hospital for paediatics, so of course I could not resist applying for the post of Nutrition Support Specialist Dietitian when this was advertised in 2000,” said Paul. The post was half clinical and half research. Among the areas of research, Paul audited the efficiencies of the milk room, which is where hundreds of special prescribed milks are produced. He also researched the occurrence and types of treatments being provided to GOSH patients with obesity. Senior staff at the hospital showed great interest, but were not keen to take action: children attending GOSH usually suffered a plethora of other and more acute health issues. So, Paul decided to develop a weight management programme for children in his spare time. He approached other health experts, including psychologist Dr Paul Chadwick, and ran a pilot project. Children with obesity attended twice weekly group meetings with their parents or carers, focusing on changing behaviours around diet and physical activity. “We were very pleased when we found the programme resulted in wide ranging health and psychosocial benefits,” said Paul.
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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F2F He shared that he had been a child with obesity. This was clearly the driver for his professional devotion. I asked why he had been overweight. “My mother had to cater to one son who was skinny and tennis-mad and another (me) who loved to play with action toys and watch videos. I just matched my brother for sports drinks and large food portions. I remember being taken to a dietitian and being told that I was fat, which made me feel even worse about myself,” said Paul. Paul wanted to research obesity in childhood further and was very pleased to be awarded a fully-funded NIHR PhD scholarship. This led to the completion of a multi-site randomised controlled trial showing the success of the Mind, Exercise Nutrition… Do it! (MEND) programme. In 2006, with the help of business-minded colleagues, it was time to leave healthcare research and employment and venture into the start-up world. The growth of MEND was explosive, following millions of pounds secured from Big Lottery, Sainsbury’s and Weight Watcher’s. To date, no family has ever paid to attend a MEND programme. Over the years, MEND has been extensively evaluated in large international trials, resulting in the publication of more than 37 peer-reviewed publications. Over 7000 group leaders in seven countries have been trained to lead MEND programmes, and over 130,000 children and parents have participated, empowering them to make healthier lifestyle choices; and, as co-founder, Paul was busier than ever. Then, ‘overnight,’ disaster hit the MEND organisation. After the NHS public health restructuring from Primary Care Trusts to Local Authorities, much of the funding for community based weight management programmes was slashed. “It is so short sighted to cut these programmes, because they are recommended by NICE as the firstline treatment and will certainly help to reduce future NHS costs. But, of course, when funding is tight, treatment is always prioritised over prevention. The truth is you need both,” said Paul. Fortunately, MEND survived these cuts and continues to grow internationally. 44
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Over 7000 group leaders in seven countries have been trained to lead MEND programmes
Recently, the YMCA of the USA chose MEND as their preferred child weight management programme, and it is currently being rolled out across their national USA network. Paul looked amused at my suggestion that plums fell into his lap. To get plums, you have to climb trees. “Let me share something,” said Paul. “When I worked as a clinical dietitian, a very well-known recipe book author contacted the department for help, but none of the other dietitians were interested. I put a lot of work into helping the author, which led to another contacting me for help, which led to me being offered a contract to write my own book (From Kid to Superkid) to support parents to raise healthy kids. This book became one of my ladders.” We talk about the fact that successful careers are usually zig-zag shaped in hindsight. Opportunities often present themselves, but it takes bravery to jump into the cold and fastflowing currents that lead to professional achievement. Paul is now active in many exciting projects and particularly focused on the development of engaging and effective large-scale digital health services. But a gap develops between us: I am a laggard when it comes to new technology and when he uses the term ‘sticky content’, I am of course thinking about toffee pudding. We may be at opposite ends in our excitement about the ability of big data to support health, but we are both surprised to find out how much we have in common. We both enjoyed our back and forth discussions. Perhaps it was the magic of the back and forth table?
ADVERTISEMENT JOB VACANCY
Specialist Dietitian
Band 6 / Professional Salary £29,181 - £38,861 plus package. Hours: 37.5 hrs per week (part time would be considered) Fixed term contract: 1 year (maternity cover) Location - Northampton An exciting opportunity has arisen for an enthusiastic HCPC registered Dietitian with excellent communication skills and self-motivation to join St. Andrew’s Healthcare, a leading, not for profit, provider of in-patient psychiatric care. This post and site provides care to men and women within medium and low secure and locked units. Meeting nutritional needs in this context can be challenging but very rewarding with the opportunity to make a significant difference to patient care. We are committed to on-going professional development and have monthly professional meetings which you will be supported to attend. This post would be suitable for a Band 5 Dietitian who feels ready to progress to Band 6 or someone already working at a Band 6 level already. This role will build on your existing dietetic skills - clinical knowledge, communication skills, motivational interviewing, case load management and collaborative working. Working as part of the friendly dietetic team, a large part of your case load would be to manage the nutritional needs of patients within the Brain injury integrated practice unit (IPU). Your dietetic caseload would be varied and could include management of nutrition support, Diabetes (type 1 and type 2), weight management, dysphagia diets, food allergies and intolerance and management of over and under hydration. Previous experience working with a variety of nutritional needs would be desirable. Support will be provided by the Band 7 Dietitians within the department and the department benefits from dietetic assistant input. St Andrew’s Healthcare has a strong ethos of multidisciplinary working and has close links with Speech and language therapy, physiotherapy and the ward teams. The dietetics team also works closely with the on-site catering team who provide a fresh cook catering service, which is tailored to patient’s needs. St Andrew’s Healthcare offers an attractive benefits package including pension, sickness policy on par with the NHS, 35 days annual leave, life cover, cycle to work scheme, childcare vouchers, healthcare cash plan, free parking and free DBS. We welcome requests for further information or a site visit, please contact Rebecca Forster (advanced specialist dietitian) on 01604 616116 or Nicola Wolfe (advanced specialist dietitian) 01604 6018686. Or apply online at www.stah.org/careers/job-search/specialist-dietitian-2 We are always looking out for talented Dietitians to join the team so if you are interested in other opportunities within the team please also send your CV specifying what you are interested in.
Closing Date: Sunday 24th February 2019
A DAY IN THE LIFE OF . . .
A FREELANCE DIETITIAN BUILDING A NEW BUSINESS At the time of writing this, I am going through a very interesting period of transitioning from permanent employment into the world of freelance dietetics full time! Evelyn Toner RD Dietitian, Sports & Exercise Nutritionist Having worked in both the NHS and private sectors, in clinical dietetics and management, Evelyn is now building her freelance career as The Active Dietitian, specialising in health and wellness, fitness and gastroenterology. Instagram: @the_active_dietitian
To date, I’ve been lucky to have had a varied and busy dietetic career, starting off in the NHS as a Band 5 with a busy general caseload, then going on to specialise in gastroenterology. During this time, I completed a parttime PgCert in Sports and Exercise Nutrition and began seeing sports clients privately alongside my NHS job. This was my first experience of freelancing and I well and truly caught the bug. After four years in the NHS in Belfast, my now husband and I upped and moved to London where I got ‘bank’ work (similar to locum) in a prestigious private hospital. I loved it there and worked hard to progress my career, climbing the ladder to become the acting Dietetic Manager. This role gave me great experience in the business world and the non-clinical side of dietetics, including marketing, service development and financial management. Alongside my full-time job, I continued to do freelance dietetic work, and recently made the scary decision to make this freelance work my fulltime occupation! Currently, I dedicate one day a week (plus weekends often!) towards building my own business, these days are varied and exciting, so I’m going to do my best to take you through a day in this new life of building a business.
06.30 – 09.30
The days I work in the hospital begin at 05.30 with a 40-minute cycle into London City for a gym session 46
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before starting work, on the days I’m working on my own business, I enjoy a slightly later start, and the alarm will go off between 06.30 and 07.30. I get to have a cup of tea with my husband while we get ready to leave the house, then I go to my local gym for a couple of hours - this is my ‘happy place’ and I need to be mindful of time, as I could quite happily while away the hours here. Depending on what day it is, my sessions will include interval training, strength training or road running. Then it’s time for breakfast – usually overnight oats with yoghurt and berries, prepped in a batch over the weekend (#mealprep!!).
09.30
My working day then begins with checking my emails, marking client emails for response later on and dealing with media enquiries immediately, as these are often timesensitive. I will then dedicate some time to social media interaction, commenting on and sharing posts on Instagram and Twitter, researching and creating content for my own pages which I run as The Active Dietitian. I find social media invaluable for networking, building relationships with other freelancers through the BDA Freelance Group’s Facebook page and through Instagram ‘pods’. It’s also a great place for finding business leads and opportunities. My role as secretary for the BDA Gastroenterology Specialist Interest Group also lends itself well to networking.
11.00 – 13.30
Late morning to lunchtime is often my ‘client time’. This may involve face-to-face consultations that I have in a local coffee shop, or virtual consultations, followed by answering client emails and reviewing food diaries. I tend to see clients for advice on IBS, the low FODMAP diet, sports nutrition, or those wishing to optimise their health and wellness - this allows me to combine my clinical skills with my own passion for fitness and healthy living. I make sure I protect some time to get outside for a walk before lunch, as it’s easy to neglect regular movement, and your daily ‘step goal’ when working from home. I’m lucky in that I’m right beside a beautiful park with a lake full of swans, so it’s no hardship to go for a lap. Fresh air always works up an appetite for lunch.
14.00
As I am in the early stages of building my business, I plan to dedicate some time in the afternoon to website, business and package development. This may be time in front of the computer, or meetings with businesses, personal trainers or fellow freelance dietitians. Perhaps I will work on developing some resources, eg, presentations, articles, diet sheets, or meal plans, depending on the leads I’m pursuing. I may go to a coffee shop in the village with my laptop for a change of scenery and some social interaction if it’s a particularly computer-heavy day.
16.30
One of my passions is recipe testing and development and swapping ingredients in traditional recipes to make healthier versions of well-known treats so that they can be enjoyed as everyday foods. One I’m working on at the moment is a lemon drizzle cake (more like a lemon bread), so I’ll spend some time on this in the afternoon and if it works out, photograph it for a blog or Instagram post! This leads nicely into preparing dinner.
19.00
As a freelance dietitian, soon to be without the support network of a ‘dietetic department’, it’s important to seek out opportunities for CPD, so in the evening I will either do some reading, watch a webinar, or attend an event - either related to dietetics or perhaps a marketing masterclass as this is particularly relevant for me at the moment. I find the BDA Freelance Group create some wonderful content and events to support the CPD of those working independently, also people post great content on social media sharing new research. So, I’ve given you a taster of what a day centred on building my business looks like. I’m excited to embark on this journey and enjoy the flexibility, autonomy and variety that being self-employed brings.
A wealth of useful dietetic resources for all dietitians and nutritionists Subscriptions to NHD are FREE to eligible dietitians, nutritionists and healthcare professionals. Visit our website here . . .
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CAREERS
DIETETICS ON WHEELS The challenges of becoming a dietitian when you are in a wheelchair.
Rasleen Kahai RD Manchester University NHS Foundation Trust Rasleen is a recently graduated dietitian, currently working at MFT within general respiratory and pulmonary oncology.
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“Isn’t she supposed to be in her room?” a paediatric doctor asked the nurse. “I think she’s a member of staff,” the nurse mumbled back. Slowly, I turned around and realised who they were talking about…me! As dietetics only has a small degree of physical patient contact, it would seem a good career for a wheelchair user. However, from my short experience in this healthcare sector, it is a battle I seem to be continually fighting. I have encountered a myriad of issues, including preconceptions from staff and patients about what my role is, and a complete lack of access. My journey to becoming a Registered Dietitian started at university, where the accessibility issues unfortunately began. Little did I know that I would be fighting the same battles as Ed Roberts, a disabled activist in the 1960s. On multiple occasions, I was unable to attend lectures because the rooms were only accessible via stairs, with seemingly no possibility of re-timetabling them, despite months of prior warning and extensive email conversations. The ongoing difficulties I frequently faced often made me question my path. Should I continue to train as a dietitian, or drop-out? Happily, my time on placements helped me reconsider. I found myself really enjoying both the hospital and the public health environment and especially working directly with patients. This reminded me why I wanted to be a dietitian in the first place – the people. Graduating brought a mix of feelings and emotions, the foremost being pride. I had proven my resilience to overcome all the hurdles I had faced. This goes hand-in-hand with the positive and tangible changes I helped contribute towards, for future disabled students, with the hope that they won’t have the
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same struggles as I did. Such changes include automated doors, wheelchairlevel lab benches, accessible ramps and dropped kerbs (to name but a few!). However, I was feeling worried as to where I would go in the future and whether I would face the same difficulties through my working life. Many dietitians I had spoken to throughout my time as a student, often told me that their dietetic departments were inaccessible. How was I supposed to practice as a dietitian if I couldn’t even reach the department? That was a sobering thought. ACCESSIBILITY IN THE WORKPLACE
When I began applying for jobs, I realised that despite the NHS being ‘disabled confident’, little information was given about wheelchair accessibility to dietetic departments. This often put the onus on me to email and find out. Just as I had thought, I found an equal split of accessible and inaccessible departments. Those who had inaccessible departments would still recommend applying, on the basis that reasonable adjustments could be made. With previous experience of reasonable adjustments not being fulfilled, I was often left feeling anxious about what could be done. Nevertheless, I applied and persisted. With a little bit of thought, innovation and a fairy-godmother manager, I can now happily say that I am working as a Registered Dietitian within a hospital with an inaccessible main dietetic department.
Graduating brought a mix of feelings and emotions, the foremost being pride. I had proven my resilience to overcome all the hurdles I had faced.
Sadly, I was not given my very own office as a reasonable adjustment, in case you’re wondering! I’m a part of the separately funded cystic fibrosis dietetic team on the ground floor. There are logistics that have been worked out internally about how I can receive and give back patient record cards when working with the main department. From a patient perspective, I often find that some patients can resonate with me and the chair: “You’re like me, disabled too”, “Taking one for the wheelchair team!” I also never have to worry about standing over patients! OVERCOMING DIFFICULTIES
Nonetheless, a number of difficulties remain. It can be tricky to take a face-to-face referral from a ward doctor, as the records are held within the inaccessible main department. Additionally, ward staff often query why I’m wearing a ‘watch’ on the ward. Unknown to them, the ‘watch’ is actually part of my wheelchair, which connects via Bluetooth to the wheel on the back. This allows the wheelchair to be electric to meet my clinical needs (as well as having a good party trick up my sleeve!). These issues are mainly resolved with better
disability awareness and education, something I hope one day will be available in all Trust inductions. On top of that, I am currently working in partnership with infection control and the health and safety team to change the foot pedal bins to automated bins. However, it’s also important to highlight that small changes can also make big differences. These can include shifting miscellaneous items which are blocking corridors, moving boxes of gloves to an accessible height at the nursing station and asking your disabled colleague if they need help reaching something. All of these positive steps remove barriers towards working independently as a dietitian in a wheelchair. Despite dietetics making it into the 21st century, in my view, we still have a long way to go until disabled dietitians have an equal and accessible working environment within the healthcare sector. However, it can also take one rolling dietitian’s experience to be shared to bring hope, awareness and improve accessibility within dietetics in the future.
dieteticJOBS.co.uk To place an ad or discuss your requirements please call
01342 824 073 (local rate)
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SKILLS & LEARNING
THE NUTRITION SOCIETY’S TRAINING ACADEMY What does the future hold for nutrition training? Education and CPD play an important role in the Nutrition Society’s aim of advancing nutritional science. Penny Hunking RD, RNutr Honorary Officer with the Nutrition Society Penny is an independent Registered Dietitian and has worked with a diverse range of companies and organisations over her career. She has written, researched and talked to consumers and professionals about numerous aspects of diet, weight management and exercise.
The need for evidence-based dissemination and informed practice of nutritional science and skills has never been greater. The increasing burden of non-communicable diseases1 is placing the spotlight firmly on diet and lifestyle interventions against a backdrop of continued mixed messaging and public confusion, with some 61% of adults citing changing advice from experts as one of their biggest causes of confusion.2 Programmes such as the ‘Need for Nutrition Education and Innovation programme’ (NNEdPro), have highlighted the need to embed nutrition education into the wider healthcare system, with emerging scientific evidence particularly vulnerable to misinterpretation.3 Dietitians and other nutrition professionals play a key role in impacting the nutritional status and health outcomes of populations,4 as well as helping to translate and disseminate nutritional science among healthcare peers and the public. Yet, with nutrition research constantly evolving, we know that even among dietitians and nutritionists, a lack of confidence in the science surrounding new or evolving topics can provide a significant barrier to integrating knowledge into practice.5 Nutrition education and continuing professional development (CPD) are, therefore, key - and play an important role in the Nutrition Society’s central aim of advancing nutritional science. THE NUTRITION SOCIETY AND TRAINING
The training section of the Society began in 2011. Since its implementation, 50
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developments in technology have led to a re-evaluation and redesign of the Society’s training programme. As a result of market analysis and consultation, the Nutrition Society Training Academy (NSTA) was launched in June last year. Focused on concise, targeted online training, as well as face-to-face workshops where required, the NSTA aims to enhance and invest in the improvement of nutrition science. In a landscape of diminished time and budgets, e-learning provides a flexible option for providing training that can reach the widest possible audience. A 2010 report commissioned by the General Medical Council, found that cost, study-leave availability and the difficulties of maintaining a worklife balance were the biggest barriers to effective CPD among healthcare professionals.6 As a result, the NSTA Committee pledged to meet your training needs as evidence-based healthcare practitioners, and we hope our current schedule demonstrates that we are heading in the right direction. Over the course of the year, the NSTA will be expanding its delivery of webinars so that you can participate irrespective of interest or career stage. The NSTA has certainly hit the ground running, delivering five live webinars to date, as well as two international workshops: ‘Understanding Scientific Publishing’ and ‘Statistical Guide for Nutrition Research’, at the Africa Nutritional Epidemiology Conference (ANEC VIII). Over 300 delegates have benefited from the NSTA’s programme so far.
HOW CAN THE NSTA BENEFIT YOU?
• Hear from leading experts in their respective fields at competitive rates. Our one-hour long webinars include a summary document for CPD reflections. • Flexible learning opportunities. Designed to be as accessible as possible, you can fit our webinars into your lunch break or catch-up after work and attend on a computer, tablet, or phone. • Group rates are available, so you can participate in the webinar collectively. If a group of you are interested in participating in a webinar, get in touch via email here . . .
• Fit your CPD around work and general life. If you miss a webinar the first time around, there will be a second chance to catch-up. We run simulated live webinars after the live broadcast, scheduled for the evenings and weekends. • Pick up practical skills as part of our blended learning sessions. Our 'Statistics for Nutrition Research' workshops, for example, include Excel and SPSS exercises.
NUTRITION SOCIETY DIARY DATES 12 February Nutrition and the Aging Immune System Webinar Part of the Hot Topic series, providing an overview of the immune system, looking at changes over the life-course and the implications of an aging population, led by Professor Philip Calder. 28 February
From Paper to Podium: Translating Sports Nutrition Research to the Sports field Webinar This will look at some of the pitfalls when translating the findings of research papers to the sporting field and present an operational framework that may guide the applied practitioner.
14 March
Statistics for Nutrition Research Workshop Designed for MSc and PhD students working on human nutrition studies, professionals with an interest, and those studying or working on large-scale human trials, this practical course covers a range of different statistical techniques.
All NSTA training programmes seek endorsement by the Association for Nutrition (AfN) and a certificate supporting your CPD is always provided. The NSTA committee are running a rolling calendar of workshops that will be continually updated, but to see which of the current programme is for you, visit www.nutritionsociety.org/events/training. The Committee are always looking for your feedback and ideas, so contact Jade Mitchell at training@nutritionsociety.org with yours.
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EVENTS & COURSES THE ROYAL MARSDEN FOUNDATION TRUST STUDY DAYS: Adult Tracheostomy Care – All You Need to Know 18th March – EVENT ID 696 Enhance your knowledge and skills to care for adult patients with a tracheostomy. The programme consists of lectures, participation, practical sessions and emergency scenarios.
Upcoming events and courses. You can find more by visiting NHD.mag.com
Foundation in Oncology for Speech and Language Therapists 27th June – EVENT ID 680 For healthcare professionals (SLTs and nurses) caring for oncology patients with communication and or swallowing disorders as a result of their oncological diagnosis or treatment, based in an acute setting, community or hospice. The Long-term GI consequences of Cancer Treatment 8th July – EVENT ID 798 For healthcare professionals with a keen interest in cancer survivorship and more particularly GI and nutritional consequences of cancer treatment within a holistic context. Click here for full details . . . www.royalmarsden.nhs.uk/news-and-events/conference-centre/ study-days-and-conferences NUTRITION SOCIETY TRAINING ACADEMY - Webinar Nutrition and the ageing immune system 12th February – 1 pm - 2 pm Click here for more . . . www.nutritionsociety.org/events/nutritionand-ageing-immune-system BNF CONFERENCE Nutrition and CVD: The Heart of the Matter 27th February 9 am to 1 pm Royal Society of Chemistry, Burlington House, Piccadilly, London, W1J 0BA Click here for more . . . www.nutrition.org.uk/component/ rseventspro/event/55-bnf-conferencenutrition-cvd-the-heart-of-the-matter.html
DIABETES CONFERENCE 6th to 8th March - ACC Liverpool Click here for more . . . www.diabetes.org.uk/Diabetes-UKProfessional-Conference NUTRITION AND HYDRATION WEEK 11th to 17th March Click here for more . . . www.nutritionandhydrationweek.co.uk RECIPE ANALYSIS: MAXIMISING ACCURACY 22nd March On behalf of Nutrition and Wellbeing, Susan Church Nutrition - Leeds Cookery School Click here for more . . . www.susanchurchnutrition.co.uk/recipeanalysis-training
dieteticJOBS.co.uk DIETITIAN - THE FOOD CHAIN (3 DAYS PER WEEK) - £27,000 PRO RATA The Food Chain is a unique charity that exists to support people living with HIV in London to access good nutrition. We now have an opportunity for a part-time Dietitian to join our small staff team. The Dietitian is a vital link in The Food Chain. You will be our in-house expert, ensuring that each and every one of the people we support every year gets the correct nutritional support to help them get well, stay well and live independently. You will ensure that we reach the right people, and get the right level of support and education to them, at the right time. As the first and regular point of contact for referrers as well as service users, you will
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have a good knowledge of nutrition for people living with HIV. For further information and a detailed job description please see our website here . . . To apply for this role please email recruitment@ foodchain.org.uk with a CV and covering letter (approx. 1000 words) explaining how you meet the experience, knowledge and competencies as set out in the job description, be sure to clearly state the job title in the subject of the email. Deadline for applications is 18:00 on Wednesday 6th February. Interviews will be held w/c 11th February.
F2F
WHY I DIDN’T TRY VEGANUARY! Unless you were hiding in a box for the whole of January, you would have heard about Veganuary,1 where people challenged themselves to follow a vegan diet for the whole month. The main reason for Veganuary was to encourage a more sustainable, plantbased diet. For some people, it was also about highlighting animal cruelty, whereas for others, it was about health. Following an entirely plant-based diet is a challenge in my eyes, but, with careful planning, it’s not entirely unmanageable. I follow a few vegans on social media and I know they cook some fantastic, well-balanced recipes. As I work in inherited metabolic disorders with patients on low protein diets, I know that there are so many vegan terrific alternatives. But Veganuary? As a mother and a dietitian, It wasn’t for me. This is why: • Although, I could give up meat for the month, giving up fish, eggs and dairy would be hard. I have tried some of the dairy-alternative products and don’t like them. The nut milks and some of the yoghurts are lacking in protein, which is the satiety factor. Eggs are such a large part of my diet, eaten daily and I don't think I would want to swap for smashed avocado on toast, nut butters, nuts, or a non-dairy yoghurt and fruit. I'm also not a cereal person anymore. • I would have concerns about consuming an adequate protein intake and gaining optimal nutrition. I would have to remember to take at least a vitamin B12 and a vitamin D supplement and would have to ensure I was getting enough omega-3. I would need to consider the trace elements zinc and selenium,
Sarah Howe Specialist Dietitian
similarly to my patients who avoid meat, fish and dairy. There are many plant-based ways to get iron and calcium, but I'd worry that I wouldn’t manage this daily. I look after a cohort of patients who cannot have lactose at all and are on calcium and vitamin D supplements, despite many having non-dairy alternatives. We always give out advice on how to get calcium from other sources. It's not impossible of course, but it is a challenge. • It would mean a lot of separate meals for my family. Personally, I would never make my young girls follow a vegan diet, as they would need to follow and eat well-planned meals to the letter. It is very easy to fill up on carbohydrates and not get enough protein, calcium, iron, vitamins B12 and D. I'd be reluctant to give them supplements and constantly rely on fortified breakfast cereals and alternative products to try and get iron and calcium into them. I know I couldn't follow a vegan diet, but I would like to try my family on more plant-based meals. For sustainability, we need to monitor how much meat we are consuming too, aiming to be more vegetarian. Some people will have had a successful Veganuary. It is doable with very careful planning, research and some supplementation. Maybe I’ll rethink when the children are older!
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. www. dietitianslife.com
Reference 1 https://veganuary. com/
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Coming in the March issue: • Paediatric food allergy
• Congenital hyper-insulinism • Healthy eating on a budget
• Pancreatitis: new guidelines • Food-first approach _______
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