Network Health Digest - March 2019 by NH Publishing Ltd

The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

March 2019: Issue 142

PAEDIATRIC FOOD ALLERGY PANCREATITIS FOOD LABELLING MALNUTRITION OVERNUTRITION

CONGENITAL HYPERINSULINISM Pages 14-19

NUTRITION AND HYDRATION

Neocate Syneo

the only AAF with Pre- and Probiotics* Help rebalance gut microbiota dysbiosis in infants with CMA with new

NEOCATE SYNEO

1,2

THE ONLY AAF WITH PRE- AND PROBIOTICS* clinically proven to bring the gut microbiota closer to that of healthy breastfed infants1

This information is intended for Healthcare Professionals only. *Accurate at date of publication, March 2019

Neocate Syneo for the dietary management of infants with: Cow’s Milk Allergy (CMA). Multiple Food Protein Allergies (MFPA). Other conditions where an Amino Acid-based Formula (AAF) is required†.

The only AAF with pre- and probiotics*. The only AAF clinically shown to bring the gut microbiota closer to that of healthy breastfed infants1. Effective resolution of CMA symptoms1,2. Supports normal growth2,3. Hypoallergenic.

†

Neocate Syneo is not suitable for use in post pyloric tube feeding, or in premature or immunocompromised infants. It is not recommended for in Professional. Neocate LCP will continue to be available for use where Neocate Syneo is not suitable.

*Probiotic Bifidobacterium breve M-16V and prebiotic scFOS/lcFOS blend Neocate Syneo is a Food for Special Medical Purposes for the dietary management of Cow’s Milk Allergy, Multiple Food Protein Allergies and oth including breastfeeding. References: 1. Candy et al. Pediatr Research. 2018;83(3):677-686 2. Burks W. et al. Pediatr Allergy Immunol 2015;26:316-322 3. Harvey BM Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ Resource Centre: 01225 751 098

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nfants with a central venous catheter or short bowel syndrome, without full consideration of risks and benefits and monitoring by a Healthcare

her conditions requiring an Amino Acid-based Formula, and must be used under medical supervision after full consideration of all feeding options,

BM et al. Pediatr Res. 2014;75:343-51.

FROM THE EDITOR

WELCOME Just a little something to keep you guessing and reading on! Mental activity, as well as physical activity, is an important part of keeping us all healthy and well into our older years. Good nutrition and hydration play a vital role in fuelling our activities, however epic or small. An Olympic athlete will hone their diet to suit their needs, improve performance and reach their goals. This should be no different for the rest of us, whatever our age or ability, to allow us to achieve our day-to-day goals and enjoy life. This month sees the annual return of Nutrition and Hydration week (11th to 17th March), an event which highlights the value of food and drink in maintaining health and wellbeing in health and social care. We bring you a variety of articles linking in with this theme, starting with our Cover Story from Farihah Choudhury on the importance of staying hydrated. Malnutrition (under- and over-) features this month, with Harriet Smith sharing insights into the current challenges of and interventions for undernutrition in the elderly, whilst Farihah focuses on overnutrition and obesity and how they are contributing to our public health crisis. Nutrition and hydration concerns are highlighted by Evelyn Newman too, as she talks us through how a network of AHP dementia consultants are supporting staff and carers to support people to live well with dementia in the Highlands. Our paediatric articles this month come from Annaruby Cunjamalay who shares her experience and insights

(3 x 7) x 5 + 3 = 108

But 108 what?

Emma Coates Editor Emma has been a registered dietitian for 12 years, with experience of adult and paediatric dietetics.

into the management of congenital hyperinsulinism. Rachel De Boer, Principal Paediatric Allergy Dietitian and Member of the Infant & Toddler Forum (ITF) brings us an overview of food allergy in toddlers and Lydia Collins-Hussey updates us on food allergen labelling in light of the proposed Natashaâ&#x20AC;&#x2122;s Law. Another trending concern at present, (especially with the possibility of food prices soaring after Brexit!), is how to eat healthily on a budget. Maeve Hanan tackles this topic by examining how realistic it is to achieve when money is tight. In addition to all the above, Rebecca Gasche discusses diseases of the pancreas, with particular focus on the recently updated NICE guidance. We welcome Karen Voas who promotes MDT working in the community. Ursula Arens checks in with multitalented dietitian Eulalee Green in Face to Face. So, did you get If you have important news or the answer to the research updates to share with NHD, or maths question? would like to send a letter to the Editor, 108 is the number please email us at of food and drink info@networkhealthgroup.co.uk emojis we have these We would love to days! But who needs hear from you. emojis when youâ&#x20AC;&#x2122;ve got NHD? Emma www.NHDmag.com March 2019 - Issue 142

9 COVER STORY Nutrition & hydration 6

News

Latest industry and product updates

14 CONGENITAL HYPERINSULINISM

39 Healthy eating on a budget How realistic is it? 43 Social care in the Highlands A look at nutrition with dementia

21 Elderly malnutrition Challenges and interventions

45 PANCREATITIS: NICE GUIDANCE SUMMARY

25 Overnutrition A UK public health crisis

29 PAEDIATRIC FOOD ALLERGY

48 F2F Interview with Eulalee Green

33 Food allergies The latest on labelling 36 Multidisciplinary teamwork Working in a community setting

50 Events, courses & dieteticJOBS Dates for your diary

and job listings

51 Dietitian's life TV debut

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

Advertising Richard Mair Tel 01342 824073

Publishing Director Julieanne Murray

richard@networkhealthgroup.co.uk

Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Columnist Ursula Arens Design Heather Dewhurst

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

www.NHDmag.com March 2019 - Issue 142

@NHDmagazine ISSN 2398-8754

PREBIOTIC OLIGOSACCHARIDES: SUPPORTING GUT HEALTH IN PRETERM INFANTS FOR HEALTHCARE PROFESSIONAL USE ONLY

The importance of supporting the gut microbiota for positive health outcomes in preterm infants Infants who are born prematurely often face multiple health concerns, including day-to-day feed tolerance, poor gut barrier function and increased risk of infection.1–3 The gut microbiota in these infants is considered to be particularly important for protection against harmful microorganisms and for the maturation of the immune system.4 Increasing evidence suggests that promoting a healthy microbiota is key to ensuring the best possible outcomes in preterm infants.2

The benefits of breast milk on the microbiota Breast milk is universally recognised and associated with the best health outcomes in both preterm and term infants by providing a unique combination of nutrients and immune-protective factors.5 A key benefit of breast milk is the promotion of a healthy gut microbiota, which is in part attributed to the presence of prebiotic oligosaccharides (OS) supporting gut intestinal flora development (figure 1).4 Breast eastffed in infant

100

Bifidobac ifidobactteria E. coli Bactteroides Bac

60 50

Bifidobac ifidobactteria E. coli Bactteroides Bac

60 50

Adapted from: Harmsen, et al. 2000

Formulaormula-ffed in infant (excl. prebiotics)

100

Figure 1 – The microbiota of breastfed infants is dominated by beneficial bifidobacteria (up to 90%) and has lower levels of harmful bacteria (such as E. coli and Bacteroides) compared to infants fed a formula without prebiotics during the first 20 days of life.4

Prebiotic oligosaccharides positively influence the gut microbiota If breast milk is not available or not sufficiently available for a preterm infant, a specific preterm formula is recommended.6 Several clinical studies have proven that a formula containing prebiotic OS (compared to a formula without prebiotic OS) helps to support the preterm gut microbiota in a number of different ways: Increasing the number of bifidobacteria in the gut (Figure 2)7 Promoting stool frequency patterns and consistency similar to breast milk fed infants7,8 Reducing numbers of infection-causing bacteria in the gut9 Potentially improving enteral tolerance in very preterm infants8,10 Adapted from: Boehm, et al. 2002 13

log (CFU/g wet faeces)

12 11 10

Prebiotic OS formula (n=15)

Breastfed reference range

Non prebiotic containing formula (n=15)

8 7

Figure 2 – Preterm infants receiving a formula with prebiotic OS for 28 days had significantly higher levels of bifidobacteria in the gut, compared to the group receiving a formula without prebiotic OS (p=0.0008).7

6 5 0

Days of feeding period

Prebiotic OS formula (n=15)

Nutriprem 1 and nutriprem 2 are the only preterm that prebiotic OS, Nonformulas prebiotic containing formula contain (n=15) proven to increase the beneficial bacteria in the gut and to support gut health. Find out more: Healthcare Professional Helpline 0800 996 1234 eln.nutricia.co.uk @nutriciaELNUK Important notice: Breastmilk is best for babies. Nutriprem human milk fortifier, nutriprem protein supplement, hydrolysed nutriprem, nutriprem 1 and 2 are foods for special medical purposes for the dietary management of preterm and low birthweight infants. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed nutriprem, nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low birthweight infants. References: 1. Calkins KL, et al. Clin Perinatol 2014;41(2):331–345. 2. Groer MW, et al. Microbiome 2014;2:(38):1-8. 3. Neu J. World Rev Nutr Diet 2014;110:253–263. 4. Harmsen HJM et al. J Pediatr Gastroenterol Nutr 2000;30(1):61–7. 5. Gartner LM, et al. Pediatrics 2005;115(2):496–506. 6. Agostoni C, et al. J Pediatr Gastroenterol Nutr 2010;50(1):85–91. 7. Boehm GM, et al. Arch Dis Child Fetal Neonatal Ed 2002;86(3):F178–F181. 8. Mihatsch WA, et al. Acta Paediatrica 2006;95(7):843–848. 9. Knol JP, et al. J Pedaitr Gastroentreol Nutr 2005;40(1):36–42. 10. Modi N, et al. Pediatr Res 2010;68(5):440-5.

18-145. August 2018.

NEWS BREXIT: PRODUCING AND LABELLING FOOD Food labelling and compositional standards exist to maintain consumer confidence and provide a level playing field for businesses. Currently, labelling rules ensure that consumers have easy access to the information they need to make an informed choice on which food to buy and eat. For example, all prepackaged food must have a name that accurately describes the product. Multi-ingredient Emma Coates food must have an ingredients list with allergens highlighted. Editor These labelling provisions are set out primarily in EU Regulation 1169/2011 Emma has been a on the provision of Food Information to Consumers (plus the related registered dietitian for 12 years, with Implementing Regulation 1337/2013 on the country of origin of certain meats). experience of adult As we edge closer to Brexit day on 29th March, our food industry is preparing and paediatric for every eventuality as best they can. Throughout 2018, the government published a dietetics. series of 106 Technical Notices (TN) setting out information to allow businesses and citizens to understand what they would need to do in a no deal scenario, so they can make informed plans and preparations. One of these TNs covers how the labelling of food and compositional standards (minimum standards for certain types of key foods) would be affected if the UK leaves the EU without a deal. What will change if there's no deal In the event of a no-deal Brexit, the UK will continue to maintain a high standard of food labelling and composition of food legislation. Initially, EU-based provisions will be rolled over, as part of the Withdrawal Act, and fixed where necessary by statutory instrument, so the rules apply as before. However, some changes would be required to reflect the fact that the UK will no longer be a member of the EU. Where the UK has its own compositional standards that do not stem from the EU, such as specific national rules on products containing meat and the composition of bread and flour, these would remain unchanged. Labelling the origin of food Use of the term ‘EU’ in origin labelling would no longer be correct for food or ingredients from the UK. Some products will require further changes. For example, labels of honey blends from more than one country referring to the EU would be replaced with more appropriate terminology: the requirement for EU/non-EU blended honey indications would be replaced with ‘blend of honeys from more than one country’, or similar wording in the domestic honey regulations. In addition, from April 2020, the country of origin or place of provenance of the primary ingredient of a food (where different to that given for the food overall) will be required on labels as part of EU rules on food labelling. The government may seek views on whether similar national rules would be appropriate in the UK when EU rules no longer apply. Addresses on food labels For prepacked products sold in the UK, the label would need to include the name and a UK address of the responsible food business operator. The food business operator is the business under whose name the food is marketed in the UK or, if that operator is not established in the UK, the importer of the product into the UK. An EU address alone would no longer be valid for the UK market. Similarly, a UK address alone would no longer be valid for the EU market and an address within the remaining EU member states will be required following EU exit. A UK address together with an EU address on the label would mean that the label is valid for both the UK and EU markets. To read more about this and to keep up to date with any further developments, visit: www.gov.uk/government/publications/producing-andlabelling-food-if-theres-no-brexit-deal/producing-and-labelling-food-if-theres-no-brexit-deal

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EATING AND DRINKING WELL WITH DEMENTIA: A GUIDE FOR CARE STAFF The Eating and Drinking Well with Dementia guide1 was developed from the Ageing and Dementia Research Centre at Bournemouth University. Since its publication in September 2018, there has been interest from all over the UK and overseas, including Dorset, Greater Manchester, Scotland and as far afield as Australia. In Greater Manchester, the guide is widely used in care homes in Salford, Oldham and Stockport. Emma Connolly, Programme Director for Greater Manchester Nutrition and Hydration Programme says, “The guide is simple yet comprehensive. It focuses on supporting people living with dementia to eat and drink well in a dignified way with positive and practical tips for care staff. It has been well received by healthcare professionals across Greater Manchester and has potential to transform nutritional care in care homes.” Early feedback from a national online survey has shown that the guide is being used on a regular basis in care homes. Over half of respondents reported that people with dementia who had poor appetites or were losing weight are eating more as a result of the suggestions and interventions in the guide. Changes that have been made include offering a variety of finger foods, snacks throughout the day and fortifying food to increase the calorie content. Changes have also been made to the dining environment, protected mealtimes and the use of adaptive cutlery and crockery. Comments indicate the impact and difference small changes can make. Following the success of this guide for care staff, work is now underway to produce a guide for eating and drinking well, specifically for family carers and friends of people living with dementia. For further information about the guide, or to receive hard copies, please contact Caroline Jones, Ageing and Dementia Research Centre via email: adrc@bournemouth.ac.uk. For references please visit the Subscriber zone at www.NHDmag.com.

LOW-COST CHANGES IN HOSPITAL CANTEENS COULD ‘NUDGE’ STAFF TO HEALTHIER DIETS Making healthy food easier to access in hospital canteens and food outlets, as well as increasing healthy options and reducing portion sizes, are the most effective ways of encouraging healthcare staff to improve their diets, according to a study1 by Warwick Medical School, commissioned by Public Health England. Using ‘nudge theory’, which has been shown to encourage healthy eating in other settings, could have a significant effect on improving the health of the workforce of the NHS, the largest employer in the UK. Healthcare staff face many barriers to accessing healthy food, such as lack of time, unpredictable and demanding workloads and inconvenient access to food. Choice architecture involves changing the environment that staff are working in, to promote healthy behaviour, often by ‘nudging’ them towards better options. The researchers found that reducing the effort required to select healthy options, or increasing the effort required to select unhealthy options, improved diets. Increasing the availability of healthy options also drove healthier diets. For example, when 75% of the snacks on offer in one hospital canteen were healthy and 25% were unhealthy, more healthy snacks were bought. Offering smaller sizes of main meals and other products alongside their standard sizes, was also shown to improve dietary behaviour. 1 Choice architecture interventions to improve diet and/or dietary behaviour by Healthcare staff in high-income countries: a systematic review’ in BMJ Open, published on 24th January 2019, DOI: 10.1136/bmjopen-2018-023687. https://bit.ly/2HrKOJx

www.NHDmag.com March 2019 - Issue 142

Advertorial feature

FRUIT JUICE

SEPARATING PULP FACT FROM PULP FICTION The National and Diet Nutrition Survey (NDNS)1 report reveals that over 60% of adults are failing to meet their 5 A Day – a long-term pattern that needs to be reconciled to improve the nation’s health. A small 150ml glass of 100% fruit juice is an easy way to get one of your 5 A Day. However, there are some conflicting opinions among health professionals on the role of fruit juice in a healthy diet. Research conducted on behalf of the European Fruit Juice Association2 found that some health professionals are cautious about recommending fruit juice due to concerns about the sugar content. Here is a handy guide to help separate fact from fiction when it comes to recommending one small daily portion of 100% fruit juice. FACT

FICTION

FRUIT JUICE IS PART OF A HEALTHY HEART DIET

FRUIT JUICE CAUSES WEIGHT GAIN

Research suggests that eating fruit and vegetables is beneficial for cardiovascular health3,4. There is also evidence that 100% fruit juice has potential cardiovascular benefits, too. One clinical trial5, which examined the effects of pomegranate juice for four weeks, reported a 6% reduction in systolic and diastolic blood pressure. Fruit juice may also be beneficial to cholesterol levels. A review8 of five randomised controlled trials (RCTs) found significant reductions in total cholesterol and LDL-cholesterol, a significant increase in HDL-cholesterol and a significant reduction in the LDL/HDL ratio when fruit juice was consumed.

Some public health bodies have raised concerns about the potential impact of fruit juice consumption on body weight, particularly in relation to overconsumption and sugar content. However, research found that fruit juice drinkers were more likely to have a healthier diet 9 and a lower body mass index (BMI)10 than nondrinkers. Evidence suggests that consumption of fruit juice within a healthy, balanced diet does not lead to weight gain. In fact, a recent RCT 11 in 78 obese adults found the opposite to be true. Participants were put on a reduced-calorie diet drinking 100% orange juice daily or an isocaloric control drink. All participants lost weight, but fruit juice consumption was associated with greater reductions in body fat and waist circumference and better preservation of lean mass compared with the control group.

FACT

FRUIT JUICE IS A GOOD CHOICE FOR WOMEN OF CHILDBEARING AGE 100% fruit juice is simply fruit that has been juiced, so the vitamins, minerals and phytonutrients from the whole fruit are also present in the juice. Fruit juice – while not equivalent to whole fruit in terms of fibre content – can help people to achieve dietary recommendations. In particular, fruit juice is a source of folate, which has been shown to be lacking in the diets of women of childbearing age; folate is important for this group as low folate is associated with an increased risk of neural tube defects-affected pregnancies. A 150ml portion of 100% orange juice (from concentrate) contains 67.5% of the Reference Nutrient Intake (RNI) for folate for women which could go some way to reducing this risk. FACT

FRUIT JUICE CAN HELP BOOST FRUIT CONSUMPTION Analysis of the NDNS data revealed that fruit juice drinkers were 42% more likely to achieve their 5 A Day10. There is no doubt that 150ml of 100% fruit juice is an effective and easy way to help people get one of their 5 A Day whilst also providing a wealth of other surprising health benefits.

FICTION

THE SUGARS IN FRUIT JUICE CAUSE A SHARP BLOOD SUGAR SPIKE AND CAN LEAD TO TYPE 2 DIABETES MELLITUS (T2DM) Foods and drinks with a high glycaemic index (GI) rapidly raise post-prandial blood glucose levels. Contrary to popular belief, 100% fruit juices do not have a high GI. International GI tables reveal that orange juice has a GI of 50, while apple juice has a GI of 41 – which are considered low GI. Although 100% fruit juice contains natural sugars, the evidence suggests that consumption of 100% fruit juices does not significantly raise blood glucose and is not related to an increased risk of T2DM. A recent meta-analysis12 found that consumption of fruit juice had no significant effect on fasting blood glucose, fasting blood insulin, HOMA-IR or HbA1c. Diabetes UK advises that 150ml of fruit juice can be part of a diabetic diet, and that consumers just need to be mindful of their carbohydrate intake for that meal13

FOR MORE INFORMATION & RESOURCES, VISIT FRUITJUICEMATTERS.UK/EN OR CONTACT BFJA@PORTERNOVELLI.CO.UK

1.Public Health England. (2019), 2. IPSOS (2018) 3. Dauchet L et al. (2006) J Nutr 136: 2588-93, 4. He FJ et al. (2007) J Hum Hypertens 21: 717-28, 5. Tsang C (2012) J Nutr Sci 1: e9, 6. Novotny JA et al. (2015) J Nutr 145: 1185-93, 7. Silveira JQ et al. (2015) Int J Food Sci Nutr 66:830-6. 8. Ruxton CHS et al. (2006) Int J Food Sci Nutr 57: 249-72. 9. Scheffers FR et al. (2018) B J Nutr. doi:10.1017/S0007114518003380. 10. NatCen Social Research, MRC Elsie Widdowson Laboratory, University College London. Medical School. (2017) 11. Ribeiro C et al. (2017) Nutrition 38: 13–19. 12. Murphy MM et al. (2017) J Nutr S, 6 (59); 1-15. 13. https://www.diabetes.org.uk/guide-to-diabetes/ enjoy-food/what-to-drink-with-diabetes/fruit-juices-and-smoothies 14. Wang B. et al. (2014) PLoS ONE 9: e95323.

NUTRITION AND HYDRATION: THE ROLE OF WATER IN BODY SYSTEMS

Everyone knows that water plays a vital role in survival. Without water, the human body cannot function at its very basic level. Even a 1% water loss – ie, mild dehydration – has negative effects on physical and mental health.1 In light of Nutrition and Hydration week this month, how can we ensure that everyone is adequately hydrated, and why should we do so? Water is the chief constituent of humans, making up 60% of a woman’s body and 50-55% of a man’s body.1 In developed countries, we are very fortunate to have safe drinking water, which is still not accessible in many developing nations. When thinking of hydration, one should not neglect the fact that there is hydration in the food we eat, which constitutes about 20% of daily water intake,1 and in drinks such as teas, coffees and juices (alcohol does not count towards this). The general guideline is around six to eight glasses (1.5-2 litres) a day.2 Eight glasses of water are not always necessary for everyone, as we get a good proportion of fluids elsewhere in our diet. Exceeding recommended guidelines, however, can result in water toxicity, cases of which have been rare and isolated, but often fatal.3 Still, between six to eight glasses per day remains a good standard. THE IMPORTANCE OF STAYING HYDRATED

The sensation of thirst is felt when you are already slightly dehydrated, so it is important to drink regularly throughout the day to avoid this, monitoring and adjusting fluid intake especially when you feel thirsty. Despite this, evolutionarily, humans know to expect hydration and correction of fluid deficits following exercise with their next meal, so fluid balance does not need to be regulated at every

moment.3 Appropriate hydration is important in maintaining healthy skin, thermoregulation of body temperature, reducing the instance of constipation, kidney and bladder issues, as well as reducing the risk of urinary tract infections (UTI), avoiding headaches, fatigue, confusion and irritability.4 The NHS launched a campaign with the tagline, ‘Eat well, drink well and keep the skin well’ in order to encourage proper hydration to prevent skin ulcers, or bedsores, from forming, especially in bed-bound individuals and hospital patients.5 Adequate hydration is also shown to have a positive effect in preventing falls in elderly people.6 Thinking of water and fluid intake often seems mundane and only complementary to a stimulating and varied diet, but hydration is crucial for the overall body system to function in such a way that supports diet and lifestyle. Hydration can be seen as fundamental to a healthy diet.

COVER STORY

Farihah Choudhury Health and Wellbeing Co-ordinator, University of Southampton Farihah is a Prospective Master’s student of Nutrition for Global Health. She is interested in public health nutrition, particularly in changing population health patterns as a result of dynamic food environments, food security and food waste, food poverty, food marketing and literacy.

REFERENCES Please visit the Subscriber zone at NHDmag.com

SWEATING IT OUT

In hot summer months, or when conducting heavy physical exercise, it is vital to drink extra fluids to replace those that are lost, due to perspiration, and to prevent heat exhaustion and heatstroke through overheating.7 Some athletes choose to rehydrate with isotonic fluids, to replace not only perspired water, but electrolytes such as sodium and potassium, and www.NHDmag.com March 2019 - Issue 142

PUBLIC HEALTH

Children and young infants have a higher proportion of bodily water, are less tolerant of heat and are more likely to get dehydrated faster.

sugar for energy. However, the use of such sports drinks for all sports is contentious and it is suggested that athletes need not consume special sports drinks in lieu of water unless they are exercising for over 90 minutes consecutively, or are drinking high volumes of water. Sports drinks are designed to replace loss of excessive electrolytes, which can lead to mild or serious hyponatraemia (low sodium) if left unchecked. Loss and imbalance of electrolytes occurs through perspiration and drinking larger than normal volumes of water.1 HYDRATION IN INFANTS AND CHILDREN

Children and young infants have a higher proportion of bodily water, are less tolerant of heat and are more likely to get dehydrated faster.1 Children naturally take less responsibility for their diets, which includes drinking water frequently, so it is vital to encourage them to drink the appropriate amount to support proper growth and development, as well as avoid any malaise. Encourage children to drink throughout the day with a fun water bottle, and ensure a drink is provided at all meal times. ENSURING THE LESS ABLE HAVE AN APPROPRIATE FLUID INTAKE

Although drinking water throughout the day usually comes as second nature to those of us 10

www.NHDmag.com March 2019 - Issue 142

who are able-bodied, or in good general health, it is harder for others to track their hydration. This includes the elderly, bed-bound individuals, or poorly individuals with, for example, incontinence, dementia or depression. Moreover, those who are acutely ill often have temporarily higher energy requirements while they recover, so it is fundamental to their full recovery that adequate hydration is taken. Healthcare professionals and carers are encouraged to tackle barriers to adequate hydration by ensuring enough fluid is available at mealtimes, as well as making an â&#x20AC;&#x2DC;eventâ&#x20AC;&#x2122; of it, such as hosting a social event such as a tea party or coffee morning. Social interaction should be encouraged, as this is thought to promote fluid intake.8 Furthermore, for those at risk of dehydration, plenty of hydrating foods should be administered including fruit, vegetables, stews and soups.5 Between 10 to 60% of elderly patients are admitted to hospital undernourished.9,10 This can be due to multiple reasons such as chronic disease, or decline due to the inability to cook and prepare food, or food poverty. Loneliness too can entail a lack of support or motivation for eating, for example, through the death of a spouse, or separation from family. Furthermore, repeat hospital visits may contribute to physical decline, as patients often find the food unappealing and unappetising, a

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

PUBLIC HEALTH feeling which is exacerbated by illness. Staff shortages combined with a lack of bespoke care often leads to difficulty in eating for those who are not physically or mentally able to feed themselves. In order to ensure these patient groups receive both calorie-rich and hydrating foods (that are also appealing), menu items that might otherwise seem indulgent or unhealthy (such as jellies, custards, milkshakes and hot chocolate), are crucial for carers and hospital staff to administer to ensure undernourishment and dehydration are avoided.11 In addition, when their ability to make choices might be otherwise compromised, aged people take pleasure in being able to choose their own drinks, so it is important to have a range of drinks on offer, from water, to squash and milk.12 CASES OF OVER-HYDRATION

Unfortunately, there have been rare isolated incidents of over-hydration which have been fatal. Usually this has been an athlete or sportsperson who has overestimated their fluid needs, leading to water intoxication, which occurs as a result of an imbalance of electrolytes following excessive water intake. This is known as exercise-associated hyponatraemia (EAH).13 Incidents have also occurred during water drinking competitions, or when taking drugs that can increase the feeling of thirst, such as ecstasy. Hyponatraemia - low sodium levels - can lead to water entering the brain and causing cerebral oedema. It has been estimated that one sixth of marathon runners develop mild hyponatraemia,14,15 which can be ameliorated by drinking sports beverages, or reducing slightly the amount of water ingested. Cases of extreme over-hydration are rare. In 1993, the first recorded case of a death from water intoxication was following the hospitalisation of seven runners at the Valley of Giants marathon in 1993.13 All seven were

taken ill after the marathon, due to pulmonary oedema. After treatment in hospital, one runner still had unsuspected hyponatraemic encephalopathy and died shortly after. In 2007, 28-year-old Californian mother Jennifer Strange was found dead in her home after entering a challenge on a radio station, whereby she was instructed to drink as much as possible without urinating in order to win a Nintendo Wii system. After complaining of a headache to colleagues, she is thought to have collapsed in her house. The first reported case of acute cerebral oedema due to hyponatraemia, resulting in a fatality, occurred in 2008 when a healthy 47-year-old English woman completed a five-hour hike spanning 10km in the Grand Canyon National Park, Arizona.14 She collapsed shortly after. Her husband recalled that she drank a lot of water and ate very little food. Initially, she fell face forward onto concrete, but regained consciousness; her condition quickly deteriorated after vomiting large amounts of fluids and she died 19 hours after her initial fall. SUMMARY

Appropriate and plentiful hydration is a firm foundation for a healthy diet and ensures that we are functioning at our optimum. The current guidelines of six to eight glasses of water a day can be adjusted due to the target group, but is a good standard to follow, to ensure the correct water intake. Different groups have different requirements and some groups face barriers to hydration that can be overcome with the help of carers and healthcare professionals. Over-hydration leading to fatalities is rare, but has been documented in the past and must be monitored, especially in those who are most at risk of over-stepping their fluid intake, ie, those performing high intensity or duration exercise.

Nutrition and Hydration Week - 11th to 17th March 2019 is a yearly initiative that has taken place every March since 2012 to highlight and tackle issues of dehydration. It encourages organisations to put on events that emphasise the importance of appropriate nutrition and water intake.

For more information, visit: www.nutritionandhydrationweek.co.uk 12

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This material is for healthcare professionals only.

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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

CLINICAL

THE MANAGEMENT OF CONGENITAL HYPERINSULINISM

Annaruby Cunjamalay Paediatric Dietitian Great Ormond Street Hospital for Children Annaruby is a highly specialised Paediatric Dietitian who has been working in paediatrics for 14 years. She has a keen interest in swimming and enjoys cooking and travelling the world.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Congenital hyperinsulinism (CHI) is a rare but potentially serious condition that presents soon after birth. The estimated incidence is 1:40,000 births, with the highest incidence rate of 1:2500 births found in consanguineous parents.1 CHI is characterised by the over production of insulin secretion from pancreatic β-cells. The risk of brain injury results from insulin action stopping the body from using alternative fuels for the brain to use instead of glucose. It is, therefore, essential to make a rapid diagnosis and commence immediate management in order to prevent severe hypoglycaemic brain injury associated complications, such as epilepsy, cerebral palsy and other neurological damage, or even death.2 The aim of treatment is to avoid any episodes of hypoglycaemia. For the purpose of CHI, hypoglycaemia is less than 3.5mmol/litre. In the absence of ketone bodies, infants with CHI are constantly reliant on the circulating blood glucose as the fuel for normal neurological functioning, hence the importance of maintaining the blood glucose concentration above 3.5mmol/ litre. CHI is often missed, as it is difficult to identify, with non-specific symptoms such as abnormal feeding, irritability, jitteriness and lethargy. Despite advanced treatment, the evidence suggests that approximately a third of children with CHI have some degree of brain injury.3 Some of the neurodevelopmental problems are often only evident at school age when higher-order cognitive functions have developed; these children present with problems such as attention-deficit/hyperactivity disorders, plus learning problems.4

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Hypoglycaemic brain injury has a lifelong devastating effect on the child and the family, which consequently has a long-term socioeconomic impact on the NHS. WHAT ARE THE SYMPTOMS OF CHI?

A child usually starts to show symptoms within the first few days of life, although very occasionally symptoms may appear later in infancy. Symptoms of hypoglycaemia can include floppiness, shakiness, poor feeding and sleepiness, all of which are due to the low blood glucose levels. Seizures can also occur due to low blood glucose levels. If the child’s blood glucose level is not corrected, it can lead to loss of consciousness and potential brain injury. SECONDARY CAUSES OF HYPERINSULINISM

This can be subdivided into several categories and often distinguished by the length of treatment required and the infant’s response to medical management. Transient hyperinsulinaemic hypoglycaemia means that the increased insulin production is only present for a short duration and often resolves in the first few weeks or months of life and is found in conditions such as: • intrauterine growth retardation • infants of diabetic mothers • infants with perinatal asphyxia

Figure 1: Focal and diffuse CHI - showing pancreas with focal lesion and diffuse disease

More research is needed to understand why transient hyperinsulinism occurs. Some syndromes present in the newborn period with hyperinsulinaemic hypoglycaemia. Up to 50% of infants with Beckwith-Wiedemann syndrome, an overgrowth syndrome, have been observed to develop hyperinsulinaemic hypoglycaemia.5 GENETICS

At present, there are seven known genetic causes of CHI, which can be inherited in an autosomal recessive or dominant manner. Abnormalities in the genes ABCC8 and KCNJ11 are the most common cause of severe CHI. Other rare causes are due to abnormalities in genes involved in regulating insulin secretion from the pancreas beta cells. Thus, testing for mutations in the ABCC8 and KCNJ1 and identification of parental origin is useful in assessing the likelihood of focal and diffuse hyperinsulinism (see Figure 1) early in the treatment. HISTOLOGY

There are two subtypes of CHI namely diffuse and focal. Focal lesions are usually small and a specific area of the pancreas is affected. Around 40 to 50% of infants with persistent CHI will have the focal form. Diffuse CHI affects the entire pancreas. It can be inherited in a recessive or dominant manner, or can occur sporadically. The management of diffuse and focal disease is different. Focal disease can now be cured and completely removed surgically if the lesions are located accurately. However, diffuse disease will require removal of almost the entire pancreas, a subtotal pancreatectomy (95%), but has a greater risk of long-term effects, such as diabetes or

pancreatic insufficiency. When this occurs, oral enzyme replacement therapy with meals is an option, but there is a chance of developing insulin dependent diabetes. Occasionally, hypoglycaemia can still occur after surgery for diffuse disease, but it is usually in a milder form, which is more responsive to medical management.6 HOW IS CHI DIAGNOSED?

This is usually done through detailed blood and urine tests taken while a childâ&#x20AC;&#x2122;s blood glucose level is low. If their blood glucose level does not fall sufficiently low during the initial period, they may have a diagnostic fast, where all fluids will be gradually reduced for a period of time until they become hypoglycaemic (3.0mmols/l or less for a very short period of time only). Once the diagnosis has been reached (or the fast has been completed), glucose is given intravenously through a drip or central venous device and/or a feed commenced to correct the blood glucose level back to normal. Once CHI is confirmed, treatment with medicines to stop insulin production is commenced. Blood samples are also sent for genetic analysis. The results of the genetic analysis helps in determining whether a child will need an 18-F-DOPA scan. 18-F-dopa Positron Emission Tomography (PET) A PET scan gives very detailed, threedimensional images of the body. It works by injecting an isotope called 18-F-DOPA. With this www.NHDmag.com March 2019 - Issue 142

CLINICAL Table 1: Criteria for diagnosing CHI Serum glucose

<3.0mmol/l

Serum insulin

Detectable at the point of hypoglycaemia

C-peptide

Elevated at the point of hypoglycaemia

Free fatty acids

Low

Beta-hydroxybutyrate (ketones)

Nil

Ketones

None in the urine

Cortisol

May be low at the point of hypoglycaemia

Growth hormone

May be high

scan, doctors are able to identify the area of the pancreas from which excessive insulin is being produced. The treatment recommended by the doctors depends on the results of the scan.7 It is important to estimate the glucose requirements to maintain euglycaemia and increased requirements can be an important diagnostic step. A normal hepatic glucose production rate in a full-term newborn is 4-6mg/kg/minute, but in CHI, this figure can be much higher.8 The glucose infusion rate (GIR) is both helpful at diagnosis and a useful indicator of the severity of CHI throughout the acute management. Calculation of glucose requirements (GIR) for enteral feeds:8 Total CHO (g) x 100 (mg) ÷ weight (kg) ÷ 24 (hours) ÷ 60 (minutes) = mg/kg/min There are two specialist centres for CHI: Great Ormond Street Hospital, London (GOSH) in the South and a joint service between the Royal Manchester Children’s Hospital and Alder Hey Hospital in Liverpool in the North. These two centres in the UK have the expertise to carry out the detailed repeated blood glucose monitoring needed to deliver treatment. MEDICAL MANAGEMENT OF CHI

The aims of treatment are: to avoid any episodes of hypoglycaemia; to provide a safe tolerance to fasting that is age appropriate; to establish feeding; to ensure optimal growth and a good quality of life. The aim is to keep a child’s blood glucose level stable at 3.5mmol/litre to 10mmol/ litre. This can be managed by using formulas with added glucose polymers in feeds alongside medicines to reduce insulin secretion. 16

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Blood glucose monitoring The MDT will teach parents about blood glucose monitoring and medications prior to discharge. Parents are advised to monitor their children’s blood glucose prior to feeding and when unwell. Upon discharge, the medical team will ensure that every child is given an individualised hypo plan, in the event that a child develops hypoglycaemia. An emergency regime is also given and explained by the dietitian. This is made up from using a glucose polymer or SOS and is given to a child during periods of illness, or when the child is unable to eat/feed or drink as normal. When children with CHI are unwell, they are at a high risk of their blood glucose levels dropping very quickly. The emergency regime is designed to give an appropriate amount of CHO for the child’s age based on average nutritional requirements and used during illness, with the aim of preventing hypoglycaemia, allowing the child to be managed at home. DIETETIC INTERVENTION

Dietetic input can be difficult initially when a child is admitted to hospital. They are fluid restricted due to medication, or they need a high IV dextrose volume to maintain blood glucose. Thus, there is less fluid available for feeds and this can prevent oral feeding. If infants are unable to meet their nutritional requirements from enteral feeds for more than seven days, then parenteral nutrition (PN) alongside enteral feeds should be considered. Breastfeeding is promoted and well supported by the MDT. Whilst infants are fluid restricted, mothers can express breast milk, but latching

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CLINICAL Table 2: A summary of the drugs used in CHI Drug

Indications

Mechanism

Diazoxide

Hyperinsulinism

Opens KATP channels and - Fluid retention stabilises pancreatic beta cells - Rarely leucopenia and thrombocytopenia - Taste changes - Pulmonary hypertension echocardiogram recommended prior to commencement - Excessive hair growth

Chlorothiazide

Hyperinsulinism

Acts synergistically with diazoxide by activating non KATP channels

- Hyponatraemia - Hypokalaemia

Nifedipine

Hyperinsulinism

Inhibits voltage gated calcium channels in the B-cell membrane

- Hypotension

Sirolimus

Hyperinsulinism

Rapamycin (mTOR) inhibitor, beta cell suppressor

- Not used regularly within CHI due to its immunosuppressive side effects - Used in rare cases when other treatment options have failed

Glucagon

Hypoglycaemia

Increased glycogenolysis/ gluconeogenesis

- Nausea - Vomiting - Increased growth hormone - Increases myocardial contractility - Decreases gastric acid and pancreatic enzymes

Octreotide

Hyperinsulinism

Activates G protein-coupled rectifier K channel

- Suppression of growth hormones - Delayed gastric motility - Steatorrhoea - Cholelithiasis - Abdominal distention - Hepatitis - Hair loss

on after feeds, or in between for comfort, should be encouraged as soon as is safe. As these infants are fluid restricted, it can be effective to use a high energy feed to meet their energy, carbohydrate, protein and growth. Alternatively, a standard infant formula can be concentrated to meet their nutritional needs, but this should be monitored. Glucose polymers Infants with CHI will often require glucose polymers, such as Vitajoule or Maxijul, added to feeds to increase the carbohydrate concentration. Glucose polymers should be added in small increments to feeds, as this can cause an osmotic load and can predispose preterm babies to develop necrotising enterocolitis. It is important that each child is meeting a safe level of protein, based on 18

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Side effects/limitations

their age. When a glucose polymer is added to feeds, this can alter the protein-to-energy ratio and can have a negative effect on growth. The proteinto-energy ratio should between 7.5-12%.8 Tube feeding Children with CHI have feeding problems and are known to have food aversions.9 They have persistent feeding difficulties, with 75% requiring nasogastric (NG) tube feeding and 93% will require anti-reflux medications.10 Many infants will have NG tubes passed a number of times, causing facial/oral sensitivity and, hence, oral feeding experiences are affected. There are also side effects of medication, which can cause feeding difficulties. Other factors, such as excessive insulin production, affect gut dysmotility. Infants also suffer from gastro-

oesophageal reflux and are unable to tolerate large volumes of feed and so vomit. Studies have linked excessive insulin production with the suppression of the hormone ghrelin, which could explain why babies are disinterested in feeds.10 An NG tube is inserted to deliver continuous feeds. If tube feeding is required long term, a percutaneous endoscopic gastrostomy (PEG) is often needed. Even if a child has an NG tube or PEG, we encourage children to feed orally, as this is essential to maintain their oral motor skills, reducing the chance of long-term feeding problems. It is important that oral feeding is established as soon as possible. Assessment and support from speech and language therapists can help a child regain the desire to eat and drink by mouth. At discharge Infants are discharged on bolus feeding in the day and continuous feeding overnight to help maintain blood glucose levels. At the start of an overnight feed, a bolus feed is given and after an overnight feed too, as the blood glucose levels can drop quickly after continuous feeding. Prior to discharge, a unique feeding plan is devised for

the infant. Infants with CHI undergo a six-hour â&#x20AC;&#x2DC;safety fastâ&#x20AC;&#x2122; to ensure that they are safe to go home and maintain their blood glucose level. Normal weaning is encouraged at six months of age in line with the current DOH recommendations. A child with CHI may benefit from the use of uncooked cornstarch, a complex carbohydrate. This can be used to allow a longer fast period overnight. Uncooked cornstarch can help with blood glucose stability and slow digestion times, which range from four to nine hours. A 5g dose is recommended with a maximum 2g/kg/dose. This is not recommended in children under one year of age due to the immaturity of intestinal amylase.8 CONCLUSION

The management of CHI can be complicated. However, once infants with CHI are stable, a degree of normal life can be achieved. Brain function in CHI can be normal if hypoglycaemia has been diagnosed and treated quickly. This can be variable depending on the amount of damage caused before diagnosis and treatment. With increased knowledge and research, the outcomes for these children are continually improving.

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MALNUTRITION IN THE ELDERLY: CURRENT CHALLENGES AND INTERVENTIONS

CONDITIONS & DISORDERS

Undernutrition has serious implications for health, recovery from illness or surgery and hospital costs.1 What’s more, malnutrition is estimated to cost £19.6 billion in England annually (2011-12 figures), which is twice as much as obesity.2 A recent report by the British Association for Parenteral and Enteral Nutrition (BAPEN) established that up-front investment in implementing the current National Institute for Health and Clinical Care Excellent (NICE) quality standards on nutritional support in adults, could result in £200 million in savings to the NHS annually, due to reduced healthcare use.2 In the UK, it is estimated that over three million people are malnourished. Of these people, 93% live in the community and 1.3 million are over the age of 65.3 Despite this, malnutrition remains overlooked within the media, the healthcare system and the political agenda. This article will look at current challenges of and interventions for malnutrition in the elderly, whilst showcasing the work of several dietitians. THE PROBLEM WITH NUTRITION RISK SCREENING TOOLS

Numerous studies have reported a lack of recognition and treatment of malnutrition within hospital settings.4 Whilst screening tools do exist, there are not nationally or internationally accepted cut-off points and guidelines for most nutrition-related variables.5 Consequently, it is difficult to make comparisons between studies, which is problematic when estimating global and national prevalence rates of malnutrition. Nutritional screening is recommended in NICE clinical guideline 32 recommendation 1.2.6 for all inpatient hospital admissions in the UK.6 However, definitions of undernutrition and nutritional risk and cut-off values for the nutritional variables measured

must be agreed to allow for consistent and evidence-based practice. Dietitians anecdotally report that the Malnutrition Universal Screening Tool (‘MUST’) score is often calculated incorrectly. This can lead to inappropriate or missed referrals, which can have serious consequences for patients. We need dietitians to collect data, analyse and publish data on incorrect and inadequate nutrition risk screening to allow for changes and improvements to be made. As an evidence-based profession, we need to justify our worth and show that we can make a difference to patient care. INADEQUATE NUTRITION TRAINING

Dietitians play an important role in training allied healthcare professionals to conduct accurate nutritional risk screening. However, the high staff turnover and limited time and resources within the NHS means that not all staff receive adequate training. Interestingly, medical students have recently been campaigning for nutrition training to be embedded within their medical school curriculum. Students state that their five- or six-year medical degrees provide as little as five hours of nutrition training, resulting in them not being confident in giving basic healthy lifestyle advice.7 Elaine MacAninch is a Nutrition Medical Educator and Dietitian. She works closely with Brighton & Sussex Medical School (BSMS) to incorporate nutrition into their degree programme. Elaine says that all BSMS students learn nutritional screening as a clinical skill, which students may be examined on

Harriet Smith Registered 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

www.NHDmag.com March 2019 - Issue 142

Coming in the April issue:

• Special needs infant formula • ONS on the ward • Dysphagia meal replacements • Liver disease • FODMAPs • Adult food allergies • Goat milk • Being a prescribing dietitian • Prebiotics

_______

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CONDITIONS & DISORDERS during their OSCEs (Objective Structured Clinical Exams). All students complete a ‘MUST’ and are required to interpret the results, discuss how they may use this information within patient management and when to refer on as appropriate. Students are also taught about refeeding risk, deciding on the best route for artificial feeding and ethical issues surrounding feeding. BSMS have included nutrition questions within the single best answer exams and nutrition topics (including nutrition in dementia care) have been incorporated into the recommended reading lists. BSMS have also designed nutrition research projects for students, and Elaine hopes that future projects will look at current practice and the doctor’s role in nutrition support. The student feedback has been overwhelmingly positive, but the challenge remains that nutrition is not always considered in current medical practice and we need to do more to work with current junior doctors. REITERATING A FOOD-FIRST APPROACH

Many allied healthcare professionals are unaware of the importance of a food-first approach in combatting malnutrition. Sophia Sarmiento, an NHS Community Dietitian, is tackling this head on in the London Borough of Waltham Forest. She is working alongside care homes to empower the staff to implement food-first methods daily. Sophia has helped to develop resource packs on nutrition and hydration, which give simple and realistic guidelines, recipes and advice. Her NHS trust found that implementing daily afternoon tea and milkshake rounds in one private care home was so successful in reducing referrals that they are rolling this initiative out in other local care homes. BAPEN completed four national surveys between 2007 and 2011 to establish the prevalence of malnutrition in adults on admission to care in the UK. Their most recent 2011 data found that one in three adults admitted to care homes in the previous six months were malnourished,8 which reiterates why a community-led approach to tackling malnutrition is so important. APPROPRIATE PRESCRIBING OF ONS

Recent audit data indicates that between 57-75% of oral nutrition prescriptions are inappropriate.9

In 2013, Wandsworth CCG released guidelines for healthcare professionals on appropriate prescribing of ONS for adults in the community.10 The guidelines reiterate the importance of a food-first approach and reinforce that ONS should only be prescribed to patients who meet the Advisory Committee for Borderline Substances (ACBS) prescribing criteria and have been screened using a local malnutrition screening tool such as ‘MUST’ and who are deemed to be at nutritional risk. It is encouraging to see that Prescribing Support Dietitians are being employed to work predominantly with GP practices and Medicines Management Teams in Clinical Commissioning Groups (CCGs) to help improve effective and appropriate prescribing of nutritional products. LACK OF AWARENESS OF THE DIETETIC PROFESSION

Dietetics is a relatively small profession in the UK and, unfortunately, this means that not all allied healthcare professionals are aware of the important work that dietitians do. Recent headlines announced that GP surgeries will be hiring 20,000 support staff as part of a major overhaul, with soon-to-be recruits including pharmacists, physiotherapists, paramedics and social workers. They failed to mention dietitians. The BDA remarked, “It is very positive to see this commitment to expanding the primary care workforce, but disappointing not to see dietitians forming a key part of these plans.” Dietitians can play a crucial role in addressing malnutrition in the community setting, which places a significant strain on primary care services. Yet our voice isn’t (yet) loud enough. A MULTIDISCIPLINARY TEAM APPROACH

Physical symptoms can affect someone’s ability to eat.11 Simple interventions, such as asking doctors to switch timings of medications and manage pain levels and asking healthcare assistants to provide appropriate menus and mealtime assistance, can help when addressing these potential barriers. This requires a multidisciplinary team approach. Additionally, attitudes of staff towards nutrition can influence whether a patient finishes their meal.12 Small changes to ward culture, such as providing www.NHDmag.com March 2019 - Issue 142

CONDITIONS & DISORDERS mealtime assistance as already mentioned, and ensuring food is within easy reach, can have a big impact. Dietitians play an important role in educating staff about the importance of nutrition and hydration and changing ward culture. SOCIAL AND ECONOMIC HURDLES

Wider socio and economic factors can also play a role in the aetiology of malnutrition. For example, widows are at increased risk of social isolation and socioeconomic vulnerability, which may affect food choices and willingness to cook.13 Those with severe comorbidities, or who are mobility-impaired, may experience difficulties accessing and preparing food, as well as being less likely to partake in social food activities.14 A review by Age UK in 2014 found that 1.6 million pensioners are in relative poverty, defined as having incomes below 60% median income after housing costs (AHC) in 2011/12. Moreover, 900,000 pensioners are in severe poverty (incomes below 50% median income in 2011/12).15 We need to ensure that these wider socioeconomical factors are prioritised in the politic agenda when tackling malnutrition. Additionally, dietitians must consider these socioeconomic hurdles when providing individualised dietary advice. IMPROVING HOSPITAL FOOD

Data compiled by Sustain, a group campaigning for better food in hospitals, found that some NHS hospitals spend as little as £2.94 per patient per day for meals and snacks.16 It’s perhaps unsurprising that some of these NHS trusts received extremely low patient satisfaction ratings for the hospital food. In 2014, the Hospital Food Standards Panel produced a set of recommended hospital food standards, which are hoped will become routine practice across NHS hospitals.17 Andy Jones, the Co-Lead for Nutrition and Hydration Week and Chair of the PS100 Group (a lobbying voice that aims to drive government legislation) believes that tackling malnutrition requires a new way of thinking in terms of nutritional guidelines. He says that the UK Eatwell Guide, which has been in place for several years, focuses on fighting obesity and reducing calories, despite malnutrition costing the UK twice as much as obesity. 24

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The Eatwell model neglects the fact that malnourished individuals need to eat more calories and energy-dense foods. Andy believes that Public Health England should take note from Canada’s Eatwell Plate, which puts the focus on all foods being healthy and that proportions and intake vary for different people’s nutritional needs. DIETETIC INTERVENTIONS

Oral nutritional interventions are indicated when any patient is taking inadequate food and fluid to meet their requirements.1 The three main approaches include food-based, ONS and organisational. This article has highlighted how a food-first approach is usually the first step when addressing malnutrition. Food-based approaches could include encouraging patients to order energy and protein dense options from the hospital menu, increasing portion sizes, offering additional snacks and puddings and encouraging patients or staff to fortify foods with high sugar or high fat foods such as butter, jam and sugar. Studies have shown that dietary counselling given with or without ONS is effective in increasing nutritional intake and weight.18 Therefore, ONS and a food-first approach are often used in combination. ONS, as already discussed, must be appropriately prescribed. It is important that dietitians work closely with patients and/or staff to ensure that ONS does not impact on appetite (ie, avoid 30 minutes before a meal) and that a patient is compliant. Compliance rates are highly variable, with one systematic review reporting compliance rates of 37 to 100%, the highest compliance being with high-energy sip feeds.19 Patients taking ONS should be regularly reviewed to maximise compliance and ONS should be discontinued if no longer indicated.10 Organisational approaches could include providing mealtime assistance, improving the eating environment and implementing protected mealtimes.20 These are all interventions that dietitians can be involved with. However, there is limited evidence to support their efficacy. Finally, enteral tube feeding may be indicated in patients who cannot achieve an adequate oral intake from food and/or ONS, or in those who cannot eat or drink safely. Parenteral feeding is indicated in individuals whose GI tract is unable to absorb sufficient nutrients, or in those who are unable to tolerate enteral tube feeding.1

PUBLIC HEALTH

OVERNUTRITION: A UK PUBLIC HEALTH CRISIS

Malnutrition is a huge health and human rights concern, with 800 million people in the world who are starving.1 ‘Mal’ from the French, translates into ‘bad’, so malnutrition literally translates into ‘bad nutrition’. Thus, malnutrition encompasses both undernutrition and, a more pressing issue in developed countries such as the UK, overnutrition, which includes overweight and obesity. Lifestyle diseases are non-communicable diseases, often exacerbated by lifestyle conditions or choices. Having risen substantially in prevalence in the last century,2 these are also known as ‘diseases of civilisation’ having arisen from the changes in modern society. In developed nations, we have the privilege of convenience foods and a breadth of food options. Commercialisation of food industries has engendered a shift towards processed and convenience foods, which are partly responsible for a change in a food environment that perhaps encourages less considered and mindful eating and more consumption of nutrient-sparse, high sugar, high fat and high salt products. The evolving human diet in itself may not be to blame, as this and a transition towards more sedentary lifestyles, where work and leisure are increasingly technologically, as opposed to labour directed, together have facilitated a culture in which more energy is often ingested than expended, leading ultimately to weight gain. CAN LIFESTYLE PLAY A PART?

It is very striking that certain communities, which have been historically isolated from trade with developing countries and commercial food corporations, have avoided lifestyle diseases until the introduction of convenience shops. One case study of the Arctic Inuit communities3 highlights that, whilst traditionally Inuit people consume a

very high fat and protein diet from the blubber of marine animals such as seals and whales – and some would associate high fat consumption with an increased risk of illnesses such as heart disease – the prevalence of noncommunicable disease was very low until convenience stores, akin to those in larger cities, were established as part of increased interactions and trade with the developing world. Another community, the Yakut, an indigenous Siberian population, has seen a prevalence of Type II diabetes rise4 with the onset of integration with the Eurasian market. Also, the first instance of documented obesity was recorded in another Arctic community, the Nenets in 2015.5,6 Further afield, a study which compared health outcomes of rural South Africans after trialling an American diet for 20 days, revealed that there were substantial changes to the gut microbiome and metabolome and changes in mucosal biomarkers, all of which indicate a heightened risk of developing cancer.7 Clearly, the adaptation of a Western diet influences the health outcomes of traditionally detached communities, not beneficially, but in quite the opposite direction.

REFERENCES Please visit the Subscriber zone at NHDmag.com

DEFINING OBESITY AND OVERWEIGHT

Obesity is defined as the build-up of excess adipose tissue. ‘Excess’ is defined according to the BMI guidelines www.NHDmag.com March 2019 - Issue 142

PUBLIC HEALTH Table 1: BMI guidelines BMI (kg/m2)

Nutritional status

<18.5

Underweight

18.5-24.9

Healthy/normal

25.0-29.9

Overweight

30-39.9

Obese

>40

Morbidly obese

(see Table 1). Clinically, a BMI of over 25 paves the way for successive grades of overweight and obese.8 Though BMI has not always been considered the most accurate method of clinically assessing body weight alone,9 when used in conjunction with measuring waist circumference (‘central obesity’), it provides a generally accurate threshold to either alert or reassure an individual or health practitioners. In this way, BMI can be viewed as a screening tool for those who do and do not need to worry about their weight. Different thresholds exist for different ethnic groups, as well as for men and women.10 Indicators of central obesity for Europeans and Afro-Caribbeans are a waist circumference of >94cm in men and >80cm in women. On the other hand, indicators for South Asians are >90cm for men and >80cm for women.11 Physiologically, men and women have different external adipose tissue distribution. Women biologically have a higher fat retention capacity, whilst men have a higher proportion of muscle. Furthermore, men have an ‘apple-shaped’ adipose tissue distribution centred on the upper body, whilst women collect in a ‘pear-shaped’ distribution, collecting more around the abdomen and the thighs. RISKS ASSOCIATED WITH OVERWEIGHT

Overweight and obesity are well-documented as increasing the risk of developing numerous secondary diseases, including cancers, cardiovascular diseases, atherosclerosis, osteoarthritis, gallstones and Type II diabetes mellitus.12 Not only does obesity exacerbate the onset of illnesses, but it can also come with a social anxiety and shame that can prevent action to reverse poor health and have a psychological effect on the individual. Overweight and obesity in pregnant mothers increases the risk of the pre-eclampsia, hypertension 26

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and gestational diabetes, plus an increased risk of caesarean delivery, a decreased ability to give natural birth after caesarean success and an increased risk of operative morbidity. Neonates and foetuses are more likely to have preterm births, be stillborn, have higher than normal birth weights and be obese in childhood. Meta-analyses show a significant increase in neonate fatality with an increase in maternal BMI.13 In 2006, it was estimated that 18% of mothers were obese at the beginning of their pregnancy,14 and this figure is likely to have risen in recent years in line with the national increase in obesity prevalence in adults. To summarise the graveness of the risks associated with overweight and obesity, the all-cause mortality risk in individuals increases greatly with an increase in BMI above the ‘normal’ measurements15 – this is a public health issue of utmost concern. THE PROBLEM IN THE UK

Undernutrition and anorexia disorders only represent around 5% of the UK’s population.16 On the other hand, the NHS reports that 26% of adults and one in five Year 6 children were classified as obese in 2018.17 In 2002, the first recorded case of Type II diabetes in children was recorded in the UK.18 Despite rates being more stable since 2010, obesity prevalence has doubled in children and trebled in adults since the 1980s.17 This is a comparable issue in several developed countries, most shocking of all in the USA. However, despite the fact that, compared to some of our European neighbours, the UK has comparatively lower prevalence of obesity and overweight, we are the nation with the most rapid increase in overweight and obesity.17 It was declared in 2014 that “obesity could bankrupt the NHS”;19 an estimated 5.1 billion pounds was spent in 2014/15 on obesity and obesity-related conditions;20 this figure does not take into account the collateral costs associated with complications of obesity. OTHER FACTORS CONTRIBUTING TO OVERWEIGHT AND OBESITY

Physiologically, the human body is more able to cope with a lack of resources (ie, starvation), than an abundance of them. Arguably, the modern diet of excess is a new phenomenon in the evolution of our bodies. There is discourse regarding

Commercialisation of food industries has engendered a shift towards processed and convenience foods, which are partly responsible for a change in a food environment that perhaps encourages less considered and mindful eating . . .

whether we have physically developed the capacity to manage excess nutrients and, thus, have no mechanism in place to neutralise the effects of over-eating.21 The metabolic control capacities of appetite hormones such as leptin and ghrelin are still not yet fully elucidated, but their role is implicated in appetite control, as well as in many other metabolic processes. There is also select evidence suggesting that the activity of certain hormones may cause some individuals to eat more or less than others. Leptin increases when food is ingested and is said to administer a satiating effect, signalling an individual to stop eating. Ghrelin, which increases when one is hungry and decreases when one is satiated, indicates to an individual that the body is low on expendable energy. Although, historically, rodent studies administering leptin to mutant obese mice were used to determine if satiation could be achieved, results have not been successfully duplicated in humans. In fact, recorded cases of leptin deficiency are very rare. Instead, it is thought that in obese individuals, the issue is not of leptin deficiency but of leptin resistance due to defective receptors or signalling pathways. There have been developments in the research into this muddy area, for example, groups currently characterising the fat mass and obesity related transcript (FTO) gene, have identified that FTO is an important regulator of body size and composition in both rodent and human studies,22 and that FTO links high-fat feeding to leptin resistance.

It cannot be ignored that food poverty and poor food literacy create an obesogenic environment for those who are most susceptible. Public Health England (PHE) published that 7.8% of children who come from high income families are obese, whereas this figure rose to 20.7% children in low income households.23 Furthermore, misunderstanding of food labelling and portion sizes contributes to over-eating – portion sizes have increased substantially in the last few decades, so inadequate consideration of how much food is enough, or too much, may contribute to unforeseen weight gain. CURRENT INITIATIVES IN THE UK TO TACKLE OBESITY

In a government clamp down on obesity, a plan was outlined in 2016, which has been gradually enforced since its announcement.24 One major component of the outline, the sugar tax on soft drinks, has been officially in effect since April 2018,25 and drink manufacturers have been told to cut down their sugar content or pay a levy, the money raised from which is being used in school breakfast clubs. Since 2016, many manufacturers have already begun to phase out and replace sugar in their drinks. Furthermore, there have been recent talks of introducing a ‘pudding tax’ for high-calorie, high-sugar desserts, such as ‘Freakshakes’. It has been reported that, by the age of 10, children have consumed the same amount of sugar as an 18-year-old.26 www.NHDmag.com March 2019 - Issue 142

PUBLIC HEALTH Tackling high-calorie foods in other categories, PHE have also announced potential plans to order restaurants to cut down on highcalorie menu items. Other parts of the outlined plan include working with schools to enforce 30 minutes of physical exercise a day during school hours and improving school dinners. Furthermore, PHE are working with food vendors and marketing agencies to mitigate the effects of damaging advertisements and offers. This includes removing buy-oneget-one-free deals from our shelves, and discontinuing unlimited refills of unhealthy drinks in retailers. Change4Life constantly pushes national campaigns to encourage a more active nation, although its impact is perhaps yet to be significant. The rapid increase in obesity and overweight suggests that an overhaul of all parts of the food environment needs to be implemented. This includes both changes to an increasingly obesogenic dietary environment and pushing the incorporation of more physical activity into daily lives. ATTITUDES TOWARDS OVERNUTRITION

There is something to say for the attitudes towards those who are overweight or obese, contributing towards a culture that does not help individuals to lose weight, or if they do lose weight, to maintain it. A culture of fat-shaming often blames individuals for choices they may have made, or situations they may have been in. This culture is reinforced by the media and a whole industry that often promotes unattainable standards for the general population. Overweight people are aware of being overweight and shaming does not force them into action.

Conversely, a peculiar new trend has arisen from what should be a positive place. In order to encourage and accept individuals as they are, body positivity has taken off to empower those who feel inadequate, or who had previously been villainised, which is a great development in mitigating feelings of guilt and shame in individuals. However, an extreme offshoot of this appears to be a positivity movement that glorifies overweight, which is unhelpful for individuals who would benefit personally from reducing their energy intake, for their personal health and wellbeing, as overweight-related malaise can severely impede quality of day-today life. However, despite the extremes of some movements within ‘body positivity’, the cause provides a reassuring platform for those who feel insecure about weight issues and it may actually encourage more of a healthy discussion, as opposed to ostracising those who struggle with their size. SUMMARY

Many factors have been pinpointed as the sole cause of obesity and many nutrient groups have been villainised in order to explain why the nation is becoming more obese. Nevertheless, it seems that a shift in physical activity levels as a result of leisure and work being more computer and technology based, combined with consumption of high-calorie and energy-dense foods which are available in abundance, contributes hugely to our public health crisis. However, there is research to be done on other factors which might have a greater role to play than previously thought and perhaps a rethink is needed about how we can overhaul an obesogenic environment that has failed a sizable percentage of the British population.

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4TH – 6TH JUNE 2019 www.mfclinics.com/keto-college 28

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PAEDIATRIC

FOOD ALLERGIES IN TODDLERS: OVERCOMING THE CHALLENGES The prevalence of food allergy is increasing.1 Identifying the culprit food, obtaining a correct diagnosis and subsequent dietary management can be difficult. This is particularly the case in children under the age of five. The number of people being diagnosed with food allergy has increased dramatically over the past few decades. The cause for this increase (and allergy in general) is not yet fully understood, but is likely to be multifactorial. Food allergy now affects about 7% of children in the UK2 with food allergy being more common in children under the age of five, an age when consuming a balanced and varied diet to help achieve optimal growth and development is key. In light of the increase in prevalence, it has become more crucial for those who work in nutrition and/or paediatrics to recognise symptoms of atopy, to be able to conduct an allergy focused history and to provide the correct advice to parents and families on diagnosis and diet management.2,3 WHAT IS FOOD HYPERSENSITIVITY?

Some people develop symptoms when eating certain foods that cause no problems to most people. This is called food hypersensitivity, a term used to encompass all food-related reactions. Food hypersensitivity can be divided into food allergy and non-allergic food hypersensitivity, ie, lactose intolerance and hypersensitivity towards sulphites. It is well recognised that, with all food hypersensitivity, perception outweighs occurrence. This is due to

Rachel De Boer Principal Paediatric Allergy Dietitian and Member of the Infant & Toddler Forum (ITF)

the vast array of symptoms associated with hypersensitivity reactions, which can overlap with other conditions such as gastro-oesophageal reflux, toddler diarrhoea and constipation. WHAT IS FOOD ALLERGY?

Food allergy is a term to encompass food-related reactions that involve the immune system. There are two major types of food allergy: • IgE-mediated food allergies - these cause a rapid onset of symptoms, where the adverse effects usually appear within minutes following ingestion of the culprit food. The symptoms can range from mild to more severe reactions, which have the potential to be life-threatening. These reactions involve an antibody called IgE that circulates in the blood. Symptoms such as hives, rashes and swelling often manifest as a result of IgEmediated food allergies. However, the most serious reactions, known as anaphylaxis, can lead to respiratory distress and a severe drop in blood pressure and cardiac failure.

Rachel specialises in the diagnosis and management of paediatric food allergies. She works within a Children’s Allergy service in a large London teaching hospital and runs her own private practice. She is a committee member of the BDA’s Food Allergy and Intolerance Group and is on the Executive Committee of the KCL Allergy Academy.

In association with the

REFERENCES Please visit the Subscriber zone at NHDmag.com

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PAEDIATRIC Table 1: The 14 main foods that can cause an allergic reaction4 Celery

Molluscs

Cereals containing gluten

Mustard

Crustaceans

Tree nuts

Eggs

Peanuts

Fish

Sesame seeds

Lupin

Soya

Milk

Sulphur dioxide (sometimes known as sulphites)

• Non-IgE-mediated allergic reactions - these are sometimes termed ‘delayed onset’ food allergies. The symptoms associated with this type of reaction generally develop after at least two hours following ingestion of the culprit food and can take as long as 48 hours to develop. Non-IgE-mediated allergy can cause a broad spectrum of symptoms, including eczema, diarrhoea, vomiting and constipation. WHAT CAUSES FOOD ALLERGY?

The causes of food allergy are still poorly understood. Food allergies and allergic diseases in general, such as asthma, eczema and hay fever, share many risk factors. However, there appears to be a number of both genetic and nutritional factors that are specific to food allergies. For example, the timing of introduction into the diet and the amount consumed appear to be important factors, as is the amount of gastric acid in the stomach. It’s also known that composition of bacteria in an infant’s gut may influence susceptibility to food allergies. More research is needed into the causes of food allergies, with the aim of developing strategies to aid prevalence reduction. Which foods are most likely to cause food allergy? While any food can potentially cause a reaction, there are 14 foods that account for the majority of food allergic reaction (see Table 1) and, as such, their presence within any prepackaged foods sold within the EU must be clearly labelled. The foods most commonly associated with food allergy in toddlers are milk, egg and peanuts. Toddlers usually outgrow their allergic reactions to milk and to eggs often by the time they go to school, whereas peanut and tree nut allergies are more likely to persist.2,3

ACHIEVING A CORRECT DIAGNOSIS OF ALLERGIES

Diagnosis of allergies can be challenging; this is especially true in toddlers and young children, in part due to their inability to communicate and also because of symptoms overlapping with other medical conditions seen more commonly in toddlers. Diagnosing IgE-mediated food allergy is somewhat easier than non-IgE-mediated food allergy, due to the fact that the symptoms are usually rapid in their onset, making it easier to identify the culprit food after ingestion. There are two useful tests commonly used to aid diagnosis of IgE-mediated food allergies:3 • blood tests called specific IgE testing (spIgE) that measure the amount of specific IgE antibodies to a certain food circulating in the blood system; and • skin prick tests (SPE). However, prior to considering these tests, it is key that a detailed allergy-focused history is conducted.5 The only method to gain a clear diagnosis of non-IgE-mediated allergy is through an elimination diet followed by re-introduction of the food. Alternative testing (such as ‘Vega’ testing, etc) is not recommended. The scientific principles that they are based on are unproven and independent reviews have found them to be unreliable. Whilst all healthcare professionals working in paediatrics and/or nutrition should familiarise themselves with the correct advice for supporting parents, the diagnosis of food allergy should be made by a medical professional such as a doctor or dietitian. www.NHDmag.com March 2019 - Issue 142

PAEDIATRIC MANAGING ALLERGIES IN TODDLERS

The optimum method in preventing allergic reactions is to identify the food that causes the allergy and avoid it. Hence the mainstay of treatment for food allergy in toddlers is through allergy avoidance. Following diagnosis of a food allergy, dietary advice should be provided by a dietitian who can advise on an appropriate dietary management plan.6 In addition to allergen avoidance advice, all toddlers with an IgE-mediated allergy should be given an allergy action plan that depicts which medications should be used in case of an accidental allergic reaction.3 Most commonly, antihistamines are recommended to treat allergic reactions in this age group; these work by blocking the effects of histamine, which is responsible for many of the symptoms of an allergic reaction. For those with more severe allergic reactions, an adrenaline auto injector (eg, EpiPen, Jext or Emerade) may be prescribed. Dietary advice The mainstay of treatment in food allergy is allergen avoidance via dietary advice. This may appear simple in theory, but can prove difficult in practice for parents and carers, and particularly for toddlers who have multiple food allergies. Advising parents on which food to avoid and offering suitable alternative foods, is key to help ensure that a toddler is meeting the nutritional requirements crucial for optimal growth and development during these early years of life.

It is important for dietitians and healthcare professionals working in food allergy to educate parents and carers by offering practical advice on which foods need to be avoided and to provide information on the suitable alternatives, how to adapt their usual recipes and to try out new ones. It is vital too, to offer advice on preventing food allergic reactions and cross-contamination when preparing meals for toddlers. It is important to support parents in becoming familiar with food labelling laws when buying prepacked foods and when eating out. European legislation dictates that all prepacked food for sale in the EU containing the allergen food groups and products thereof should be clearly labelled.4 Despite this, parents should always be advised to read the full ingredients list to be thorough in ensuring any meals or recipes do not contain the food that may cause the allergic reaction in their toddler. When advising families on allergen avoidance, it is also important to be clear on the level of restriction required. Whilst some toddlers will need to completely avoid an allergen, including possible traces, others will be able to include the allergen in certain forms, eg, many children with IgE-mediated milk and egg allergy can tolerate these foods in their baked form.7 Lastly, guiding parents through reintroduction of the allergen, either in a hospital setting for those with IgE-mediated allergy, or at home in those with non-IgE-mediated allergy, is an important part of the dietary management for any toddler diagnosed with food allergies.

THE ITF: WHAT WE DO The ITF promotes best practice in healthy habits from pregnancy to preschool through reliable clear evidence-based advice and simple practical resources aimed at practitioners, healthcare professionals and parents. @InfTodForum www.facebook.com/InfantandToddlerForum www.infantandtoddlerforum.org For more information and practical advice on food allergies and all things nutrition in children under the age of five, see ITFâ&#x20AC;&#x2122;s range of factsheets for healthcare professionals at: www.infantandtoddlerforum.org/health-childcare-professionals/factsheets For more information on face-to-face training for healthcare professionals, contact the forum on email at: info@infantandtoddlerforum.org ITF is supported by an unrestricted educational grant from Danone Nutricia Early Life Nutrition. The views and outputs of the group, however, remain independent of Danone Nutricia Early Life Nutrition and its commercial interests.

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FOOD ALLERGEN LABELLING: AN UPDATE ON WHERE WE ARE NOW It is estimated that 1-2% of adults and 5-8% of children have a food allergy in the UK, which equates to around two million people. This does not include those with food intolerances or conditions, such as coeliac disease, who also rely on food allergen labels. Approximately 10 people die every year from food induced anaphylaxis.1 A recent study2 conducted in the Netherlands where EU labelling laws are followed, showed that accidental food allergy reactions were mainly from prepackaged foods and meals outside of the home, which is why it is important that accurate information about allergens is provided on food products, to ensure that those with allergies can make safe and confident food choices. Recently, food allergen labelling has been in the public eye following the inquest into the tragic death of Natasha EdnanLaperouse, who had a severe allergic reaction to sesame, an ingredient in a sandwich she had bought at a Pret a Manger outlet. It did not have allergen information on the label because it was made onsite and such allergen labelling is not mandated by law. Natasha’s parents have since been campaigning for ‘Natasha’s Law’ which would require full ingredient labelling on all prepacked foods for direct sale. WHAT ARE THE CURRENT LABELLING LAWS?

In December 2014, European food labelling laws came into effect to ensure that the 14 most common allergens are clearly identified on a food product (eg, in bold or highlighted). These allergens are listed in Table 1 on page 31. The EU law applies to all packaged and manufactured foods and drinks. For goods that are bought loose (from a bakery, deli, or café, for example), customers may be given this information verbally, or in an allergy folder kept on the premises.

Precautionary allergen labelling (PAL) is not governed by law and consists of voluntary statements usually presented in an allergy box, stating ‘may contain’ or ‘not suitable for those with X allergy’. It can be difficult to interpret the risk of an allergic reaction with these statements, as they are often used on many products. There can be some confusion about the difference between a ‘prepacked food’ and a ‘prepacked food for direct sale’ (PPDS). Prepacked foods, such as a food manufactured for a supermarket (eg, a ready meal) must have an ingredients list with any of the 14 main allergens clearly stated. PPDS, such as sandwiches, baked goods from a bakery, or fresh uncooked pizzas from a deli counter, are different as they are packed on the same premises as they are being sold. Currently, these foods are not required to list ingredients, as it is expected that the consumer will be given this information verbally by a member of staff if requested.

PUBLIC HEALTH

Lydia Collins-Hussey Paediatric Allergy Dietitian, Oviva UK Ltd Lydia has been working in allergy for the last five years, initially in the NHS and now for Oviva UK Ltd (https://oviva. com/uk/en/). She is currently the Secretary for the BDA Food Allergy Specialist Group (FASG).

REFERENCES Please visit the Subscriber zone at NHDmag.com

CONSULTATION ON CHANGING ALLERGEN INFORMATION LAWS FOR PPDS

There is now a consultation out for amending the 2014 food labelling law for PPDS amongst DEFRA, the FSA in England, Wales and Northern Ireland, as well as Food Standards Scotland (FSS) and the DHSC.3 The document highlights four policy options to help improve allergy labelling for food for direct sale, as shown in Table 1 overleaf. Option 1 is non-regulatory whereas 2-4 would be regulated by law. www.NHDmag.com March 2019 - Issue 142

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PUBLIC HEALTH Table 1: Policy options for prepacked foods for direct sale

Policy option 1

Promote best practice around communicating allergen information to customers. This would not require a legislative change but would continue to support best practice by encouraging businesses and consumers to review knowledge and skills to ensure a safer environment for consumers.

Policy option 2

‘Ask-the-staff’ labels on packaging with supporting information available for consumers in writing. Food prepared for direct sale would include a label or sticker on the food advising the consumer to ‘ask the staff’ about allergens. When asked, staff would have to provide supporting information on the 14 main allergens, or provide a full ingredient list.

Policy option 3

Mandate name of the food and allergen labelling on packaging of PPDS foods. Requires the 14 main allergens to be listed on the product.

Policy option 4

Mandate name of the food and full ingredients list labelling, with allergens emphasised, on the packaging of PPDS foods. Requires that full ingredients of the product are listed and the 14 main allergens emphasised on the label.

Table 2: Advantages and disadvantages of each policy option regarding allergen information for foods for direct sale Policy option

2 3

Advantages

Disadvantages

– Flexibility for business – Potential for big public health campaign to raise awareness – Can be implemented quite quickly in comparison to changing law

– Not regulated – Some business’ may not change practice – Consumer may not feel reassured as no formal change in food labelling law

– Alerts and reminds the consumer to check if a product is safe

– Time consuming in a busy environment (such as busy sandwich shop) – Staff need to be regularly trained

– Gives clear labelling of the 14 main allergens

– Takes time to change law – Increased cost for business

– Full ingredients list allows for those with allergies outside the 14 main allergens to be notified – Consumer fully informed about product

– Takes time to change law – Challenging for small businesses, which may cause businesses to remove products – Increased cost for businesses

Each option has its advantages and disadvantages (see Table 2). The policy is still out for consultation online until the 29th March 2019.4 DEFRA and the FSA are hosting workshops for those living with allergies so that all views can be expressed. WHAT OTHER LABELLING SUPPORT IS THERE?

Consumers can sign up to ‘allergy alerts’ through Allergy UK, Anaphylaxis Campaign or the FSA, informing them of any product recalls of prepacked food products. A product recall could be because the allergy labelling is missing, or incorrect, or if there is any other food allergy risk, such as cross contamination. There are also useful apps available,

such as FoodMaestro and Spoon Guru,5 which help customers identify foods which are safe to eat by scanning the bar code of a food product. For PPDS, taking extra care is necessary and, until the laws do change, consumers need to continue to ask staff members at outlets for information regarding food allergies. CONCLUSION

There is still uncertainty on what the future for food labelling will bring to the UK, especially when we leave the EU. However, it may also be an opportunity to add extra measures to ensure that consumers with allergies feel safe and confident in buying food products. www.NHDmag.com March 2019 - Issue 142

SKILLS & LEARNING

MULTIDISCIPLINARY TEAM WORK IN THE COMMUNITY SETTING A multidisciplinary team (MDT) is found to be an increasingly effective resource in clinical practice, involving a variety of professionals using their knowledge, skills and best practice across service provider boundaries.

Karen Voas Community Dietitian Betsi Cadwaladr NHS Trust Karen has been on community rotation for about six months and more recently commenced a new prescribing support role. She has an interest in nutritional support and enteral feeding and is also involved in the North Wales North West BDA Branch as Event’s Organiser.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Each professional involved in an MDT shows different and unique skills, which, combined, can be useful for the priorities and clinical needs of patients. The team is then better able to make decisions on the care and social situations for patients.1 Patient cases are ever more complex, not only for dietitians, but for other members involved with the patient. No patient case is in isolation. MDT relationships in healthcare are now more vital than ever. They have been increasing and are more diverse and more dynamic, with a wider variety of professionals aiding a team in the complex decisions that are involved with patient cases and health and social care pathways. An MDT in healthcare includes professionals who are involved in the single patient health journey (see Figure 1), such as dietitians, speech and language therapists and social workers. The differing professions with their different areas of expertise meet regularly to discuss their work. This ensures that each patient in the community setting has an effective care plan suited to their needs at that time. This may include decisions to withdraw care, or to commence funding for nursing home placement. As outlined in the NHS Five Year View, the model of care we should be giving patients is to provide the right care at the right time for the right reasons. This relates nicely to MDT working, bringing a variety of disciplines and knowledge together in order to provide the correct treatment.2 The competence and skill set can be different from one MDT to another,

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with each individual bringing different ideas, attitudes, experiences and values to the team, which in turn can impact on the team’s knowledge, behaviour and skill set. It has been shown that this has positive effects on the dynamics of an MDT and on how effectively they function together.3 The key to successful MDT working has been shown to be good communication along, of course, with good team work. Regular meetings, discussions and written communication is, therefore, vital. Meetings don’t need to be weekly, but certainly should be on a regular basis, so that all team members can come together to discuss patient cases and find out more about the priorities of the differing professionals.4 Meetings can provide an opportunity to develop a rapport and build relationships with other professionals who are involved in the patient care. Evidence is strong to suggest that effective MDT working can improve the overall care and experience of the patient and can provide better outcomes in cancer patients, dementia patients, in paediatrics and with eating disorders.5,6 A systematic review of MDTs in cancer services has found that there are improved outcomes, increased rates of survival and patient satisfaction when there is an established MDT.7 Within my role, I am involved in a community MDT, which includes occupational therapy, physiotherapy, nurse practitioner and me as the dietitian. Overleaf is an example of a community patient case study, where all these disciplines have been involved in the patient care.

Figure 1: Members of a dietetic multidisciplinary team

Table 1: Benefits of MDT working Reduction in hospital admissions

Cost effective care

Improved patient care

Clear safe plan for ‘high risk’, vulnerable and unwell patients in the community

Better communication between professionals

Better relationships between primary and secondary care (GPs)

Smoother transition from acute to community settings

Inter-professional working

Table 2: Key factors for an MDT approach NICE guidance (2016) suggests that there are key factors needed for a successful MDT approach • Patient-centred care • Shared goal, objectives and agenda • Shared information, technology and patient data, which all can access • Co-location, geographical interaction between everyone • Target for a high-risk population • Physician integration

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SKILLS & LEARNING COMMUNITY MDT CASE STUDY 62-year-old Male Diagnosis: Idiopathic Pulmonary Fibrosis, prostrate issues, anaemia, shortness of breath on exertion. Social history: Lives in a bungalow. Wife suffers with Multiple Sclerosis (MS). On home oxygen. Unable to walk long distances. Taking a variety of ONS which a locum GP had prescribed on referral to dietitian. District nurse and ANP visit fortnightly to weigh and check oxygen. Weight: on referral: 66.2kg Height: 1.71m BMI: 22.7kg/m2 Usual weight: 70kg â&#x20AC;&#x201C; 5.5% weight loss in six months; significant weight loss Locum GP had commenced him on a variety of ONS, including powdered and shot variety, prior to an outpatient appointment with the dietitian. He had already been given food-first advice and, where possible, was trying to implement this into his diet, including regular snacking on higher calorie foods and also adding food fortification methods into his foods. ASSESSMENT On initial assessment, it appeared that he was not keen on the supplements given to him by the GP. He described some taste fatigue and feeling of fullness, which was impacting his own intake at mealtimes. He disliked milk to drink on its own, but was happy to have it mixed in with the supplements. He agreed to have some of the ONS cancelled. The main dietetic issue was the fact that he was a carer for his wife who was suffering with MS. By the time he had cooked their meal, he seemed to come to the dining table where he had lost his appetite and became breathless due to the exertion to the dining room. REVIEW On review, he was really struggling with his appetite and, as part of the MDT working collaboratively, his weight was regularly monitored on a fortnightly/monthly basis by the district nurses and advanced nurse practitioners and it continued to drop. He was admitted into the acute setting, where he was quite poorly and I was contacted by the MDT team consultant who was keen for urgent dietetic review in order to establish if he was appropriate for enteral feeding. On review, he had a change in medication as the MDT aimed together to try get him meals on wheels. Other ways of increasing his intake were discussed by the team, including using different style supplements, eg, juice style, to try and optimise his nutritional status. When he had changed his medication, his appetite increased dramatically and he was able to gain the weight he had lost without the need for enteral feeding. This was a truly successful outcome and shows how working together with all members of the MDT optimises patient care. CONCLUSION

Within the community setting, as part of my current role, I am always liaising and working with the MDT. I have consistently found that when working and communicating regularly with the whole team, a full holistic approach can be taken for each patient. Understanding each MDT discipline can have a huge impact on the overall care of the patient during their health journey. Specialist nurses, or nutritional support nurses and advanced nurse practitioners can be useful healthcare professionals to encourage patients and discuss action plans, to weigh patients and provide further information 38

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for referrals. They can be seen as vital in the management of malnutrition, as well as being an important point of contact. I feel that I have a brilliant professional relationship with the MDT. We meet on a weekly basis in order to discuss patients, discuss future plans of effective working and chat through the priorities of the differing disciplines at that time, for example: mobility for physiotherapists, hydration for dietetics, etc. The benefits of MDT working for both patients and professionals are paramount in my opinion, to both patientcentred working and building professional relationships.

FOOD & DRINK

HEALTHY EATING ON A BUDGET

This article examines how realistic it is to eat a healthly balanced diet when money is a concern. Opinions can be divided on this topic. On the one hand, people often feel that items such as fruit, vegetables, nuts, lean meat and fish are expensive to buy on a regular basis. But, on the other hand, many healthcare professionals feel that following healthy guidelines can result in cost-savings, when compared with reliance on convenience food. SOCIAL DETERMINANTS OF HEALTH

The WHO defines the social determinants of health as, ‘the conditions in which people are born, grow, live, work and age [which are] shaped by the distribution of money, power and resources at global, national and local levels [and are] mostly responsible for health inequities’.1 For example, studies have found that socioeconomic factors, such as having a low paid job and living in a socially deprived area, are associated with below average health.2 These social determinants of health can directly hinder nutritional intake in a number of ways. For example: • not enough money to buy sufficient food; • a lack of cooking skills and cooking equipment; • limited time to prepare and plan meals; • limited access to food shops (which may include limited transport options). This can lead to food poverty, which is the inability to access a nutritionally adequate diet in socially acceptable ways.3 If somebody is suffering from food poverty, then following healthy eating guidelines is unlikely to be a possibility. In this case, the priority will be sourcing

sufficient food. Unfortunately in these situations, the individual tends to have little control over what food they have access to. It is now estimated that more than 500,000 people in the UK rely on food parcels, an increase on previous years.4 Food bank locations in the UK can be found on The Trussell Trust website (www.trusselltrust.org). Therefore, the first factor to consider is the degree to which finance plays a part. Is the individual hoping to save some money on the weekly shop, or are they suffering from food poverty?

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

HOME-COOKING VS CONVENIENCE FOOD

Some studies have found that cooking at home is associated with improved health and cost savings as compared with eating out and using convenience food.5-7 But, of course, this will depend on the type of ingredients used and food eaten, regardless of whether they are made from scratch or preprepared. Processed foods have been getting a particularly bad reputation recently, with the focus on reducing reliance on ‘ultra-processed foods’. Convenience food is often higher in fat, salt and sugar. However, there are also plenty of healthy and affordable processed options available, including frozen fruit and vegetables, tinned fish, pulses, hummus and wholegrain bread, etc. A study from 2012 found that 100 meals produced from five popular recipes books were higher in calories, fat, saturated fat and sugar, but lower in fibre, as compared with 100 supermarket ready meals.8 Processed food and convenience meals can also be a vital source of nourishment for those who struggle with cooking.

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FOOD & DRINK

Swap expensive brand names and ‘organic’ items for supermarket own-brand versions. Great value can be found at wholesale stores, if you have access to one.

A useful money-saving strategy is to buy food in bulk, cook in batches and freeze for future use. However, this isn’t always realistic. For example, those who are living by pay cheque to pay cheque often can’t afford to buy in bulk. Similarly, some people don’t have the necessary cooking skills, access to cooking facilities, or storage space available. It is also unlikely to work for some people who have hectic schedules, chronic medical conditions, or disabilities. So, it really depends on the type of processed foods used and the individual’s circumstances, meaning that processed foods as a whole shouldn’t be shunned. REDUCING FOOD WASTE

When planning ahead is a realistic option, this can be a great way of saving money related to food. Importantly, this can help to reduce food waste – which is really important for the environment, as well as our wallets. For example, in the UK, the average household is estimated to lose £470 per year due to avoidable food waste (or £700 for those with children).9 Planning meals and preparing shopping lists can also reduce the need to buy food ‘on the go’, which often works out more expensive than preparing meals or snacks at home. Food waste can be further reduced by freezing or refrigerating leftovers, so that these 40

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can be consumed at a later date (within food safety guidelines: www.food.gov.uk/safetyhygiene/chilling). Having an awareness of portion sizes can also help to reduce food waste. This can mean that less money is spent on food which may not be eaten, or may be thrown away. EATING MORE PLANTS

Consuming a well-balanced, mainly plantbased diet is associated with positive outcomes in terms of heart health and cancer risk.10 But plant-based diets can also have cost-saving benefits. One study from America compared the cost of following an economical version of the US healthy eating guidelines (MyPlate) with a plant-based diet. The results showed that the MyPlate diet cost $53.11 (roughly £41) per week, whereas the plant-based diet cost $38.75 (roughly £30). This worked out as a cost-saving of $746.46 (roughly £575) per year as a result of following a plant-based diet.11 However, adopting a fully plant-based diet in a balanced way may not be realistic or appealing for everybody. Including a few meatfree meals, or meat-free days, per week may be a more realistic option for many people. THE IMPACT OF FAD DIETS

Avoiding unnecessary restrictions and faddy diets may also help to save money. For example,

Table 1: Budget-friendly shopping hacks • Swap expensive brand names and ‘organic’ items for supermarket own-brand versions. • Check the discount section of supermarkets in the evening. But try not to buy something purely because it is on offer – it isn’t a bargain if you don’t actually need or want it! • You can beat confusing offers and pricing by comparing how much a food costs per kilogram instead of the overall price. • If you can afford to buy in bulk it can work out cheaper in the long run, for example, a 1kg bag of rice is often cheaper per kg, as compared with a 500g bag (but not always, so check the label). • Frozen versions of berries, vegetables and fish tend to be cheaper. • ‘Vegetable oil’ in the UK and Ireland is usually 100% rapeseed oil, which is a healthy and affordable oil to cook with. • Supermarket own-brand oats are a really healthy and affordable staple food. • Cheaper cuts of meat include: mince, brisket, chicken thigh, pork belly and neck of lamb.15 • Tinned lentils, beans and chickpeas can be a handy way to add protein and fibre to a meal, and this can also save money if it is used to replace meat once or twice per week. • Use versatile and affordable options to add flavour, without adding too much salt. For example: low salt stock cubes (you can use half at a time to reduce the salt and cost further), dilute low salt soy sauce with water (which also makes it go further), use supermarket brand pepper, herbs and spices. • Stick to your shopping list and don’t go shopping on an empty stomach. Following these classic bits of advice reduces the risk of buying unnecessary food which may go to waste. Studies have found that we are more likely to buy more food and non-food items when we are hungry.16 • It can work out cheaper to buy from a fruit and vegetable shop and butcher, rather than getting everything in the supermarket. • It’s worth checking discount stores, as they can have great deals on things like nuts, seeds and tinned pulses. • Great value can be found at wholesale stores, if you have access to one. • If you are really organised, you can use online price comparison websites (such as, www.mysupermarket.co.uk/).

a recent study found that gluten-free products were 159% more expensive as compared with gluten-containing products.12 From a nutritional perspective, this study also found that glutenfree products tended to be higher in fat, sugar and salt; but lower in fibre and protein than gluten-containing options. So, unless there is a medical reason to avoid gluten, it makes sense from a health and financial point of view to avoid a gluten-free diet. Similarly, a cost analysis of low-carbohydrate diets found that, ‘the cheapest possible lowcarbohydrate diet costs about triple the cost of the cheapest diet with no constraint on carbohydrate’.13 Studies have also found that low-carb diets may worsen health outcomes, as compared to diets which contain a moderate amount of carbohydrate.14 Therefore, avoiding strict or faddy diets is likely to save money and be better for our health.

MONEY-SAVING FOOD SHOPPING TIPS

There are several habits that can help to reduce the cost of the weekly shopping bill (see Table 1). But it is important to bear in mind that these may not be feasible for everybody. For example, some of these tips involve extra time and planning, access to a variety of shops, storage facilities, access to a freezer and literacy skills. CONCLUSION

There are many strategies that can promote a healthy balanced diet while also saving some money, including shopping wisely, reducing food waste, avoiding fad diets and eating a more plant-based diet. However, the reality of being able to use these strategies is strongly dependant on individual circumstances. In particular, the increasingly common issue of food poverty can shift food-related priorities from a healthy balanced diet, to sourcing enough food to get by. www.NHDmag.com March 2019 - Issue 142

TASTE

FOR YOURSELF

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SUPPORTING PEOPLE TO EAT WELL AND LIVE WELL WITH DEMENTIA

SOCIAL CARE

There are an estimated 90,000 people living with dementia in Scotland. An estimated two thirds of them live in the community and one third in care home settings.1 Dementia is increasingly becoming part of the core remit for allied health professionals (AHPs) in acute settings, as people with dementia are more likely to be admitted to hospital than those without. This may be due to co-existing conditions and/ or secondary complications of dementia, such as falls, fractures and infections.2 Scotland has developed a network of AHP dementia consultants, working as part of a national network to support the staff and carers who are themselves supporting people to live well with dementia. In the autumn of 2017, Alzheimer Scotland launched a national AHP strategy ‘Connecting people connecting support’, which is the first policy of its kind in the UK. This, in turn, underpins the delivery of the national dementia strategy for Scotland launched in June 2017.3 The active and independent living programme (AILP) was developed with six areas of priority work streams, including dementia. Its vision is that: ‘Allied health professionals will work in partnership with the people of Scotland to enable them to live healthy, active and independent lives by supporting personal outcomes for health and wellbeing’.4 People are living longer with multiple morbidities and complex care needs. The use of polypharmacy can create its own challenges because of the many interactions, side effects and complications, which people experience. Dietitians, like other AHP groups, have a great opportunity to realise their full skill-sets and work in new ways to deliver support and enablement for people with dementia. People with dementia are more likely to become malnourished, so

dietitians are often asked to assess and advise care staff and cooks on the best way of delivering and presenting appetising, safe, high quality food and drink. The role of public health dietitians in promoting healthier choices is also important in order to encourage the Mediterranean style approach to eating and the benefits linked to longer life and wellbeing. In care home settings, there are between 50-70% of residents living with dementia.5 Approximately 70% of these will develop a swallowing difficulty and it is estimated that 70% will be at risk of dehydration, while 50% will be at risk of malnutrition. Dysphagia is linked to all neurological conditions and requires great care and flexibility as it becomes more pronounced with disease progression. UK dietitians and speech and language therapists are currently working closely with health and social care staff and caterers to support the widespread implementation of the IDDSI guidelines.6 Care cooks do not always have the specialist catering skills needed to prepare appetising, safe and varied texture modified meals and snacks. In Highland we are currently investing in this staff group by developing a bespoke catering qualification in conjunction with University of Highlands and Islands (UHI), the Care Inspectorate, local care providers and Scottish care. Dementia should no longer be viewed as a specialist topic of practice since dietitians are likely to work both directly and indirectly with service users and family members who live with the condition. Their skill is to translate the science of therapeutic dietetics into a practical level of understanding for the

Evelyn Newman Nutrition and dietetics advisor: care homes NHS Highland Award winning dietitian, Evelyn Newman, is well known throughout the profession for her writing, volunteering with the BDA and innovative work. She currently holds a unique role in The Highlands. @evelynnewman17

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SOCIAL CARE

wider population. Public health colleagues have an important role in promoting the preventative benefits of healthy eating to live well for longer. Clinical dietitians will have greater opportunities to influence and encourage nutritional support for those who lose weight and have altered eating behaviours linked to living with dementia. In the Highlands, health and social care staff have proactively promoted the benefits of a person-centred food-first approach to living well, encouraging carers to engage people with dementia in proactively making choices about what meals, snacks and drinks are provided to them. One method, which has been successful, is ‘Strictly come dining’, where residents are given small portions of foods to try; they then rate them using a visual thumbs up or down sign. Here are some other suggestions: • Building tasting sessions into activities also allows people to try a broader range of food than they might feel confident about choosing themselves, eg, using a buffet selection of crackers, oatcakes with a variety of cheeses and patés. Taste-testing a variety of flavours of squashes, smoothies and juices encourages a higher fluid intake and reduces ‘menu fatigue’, whilst also influencing the choice of drinks available. • Food tasting can also encourage people to reminisce, eg, offering residents a choice 44

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of older style biscuits, such as Penguins, Wagon Wheels, Club, Jammie Dodgers etc, or a selection of ice lollies, such as Fabs, Rockets, Mini Milks, Strawberry Splits. • Asking people to recall their favourite, or childhood, celebrations, such as Christmas, Easter or birthdays, will often unlock a memory of the type of food and drink that was offered, who was there and a whole host of other social history that many of their families may not even be aware of. All this information allows staff to consider the best way of testing new menus and tempting people to eat and drink better. • ‘Show and tell’ at mealtimes allows residents to choose meals at the point of service, taking a sensory perspective (how it looks and smells) rather than expecting people to choose from a menu. • Occupational therapy colleagues can offer helpful, practical advice too. For example, the use of coloured plates and cups against a background of a plain tablecloth has been shown to support more independent eating and drinking, and is used to support people to eat better in many of the care homes across Highland. My role includes supporting the thousands of unpaid carers across the Highlands in raising awareness of how best to support loved ones to eat well and live well. Carers Scotland provides a range of useful, evidence-based resources, offering ideas to help carers help their loved ones.7 Food fact sheets, covering a range of dietary topics and key facts about the role of dietitians working with dementia, are helpful resources to encourage self-care and support an easy access evidence-based learning culture for staff, whether they be carers or cooks.8 I conclude by challenging colleagues to consider how they proactively adapt their practice to engage the views of people living with dementia and develop a truly personcentred model of food, fluid and nutritional care. Suggested reading Blog: Let’s Talk about Dementia: www.alzscot. org/talking_dementia Twitter @AhpDementia

CONDITIONS & DISORDERS

DISEASES OF THE PANCREAS: NICE GUIDANCE SUMMARISED Throughout 2018, NICE updated their guidance on managing patients with diseases of the pancreas, including pancreatitis and pancreatic cancer.1,2 This article aims to give an overview of the guidance on dietary recommendations and how HCPs can support this patient group. The pancreatitis NICE guidance NG104 was updated in September 2018.1 This covers advice for both acute and chronic versions of the disease. The guidance initially begins with advising that the patient and their families are provided with written and verbal information on what pancreatitis is, proposed investigations, long-term effects of pancreatitis and the harm caused by smoking or alcohol. Nutrition advice is also mentioned, which includes providing advice on pancreatic enzyme replacement therapy (PERT) if needed. As HCPs, when seeing pancreatitis patients, we often link in with GPs. The NICE guidance emphasises that the information passed onto GPs should include the following where applicable: • detail on how the person should take their PERT (including dose escalation as necessary); • HbA1c testing to be offered at least every six months and bone mineral density assessments every two years. General lifestyle interventions are discussed in the introduction to the guidance and state the following: • Advise people with pancreatitis caused by alcohol to stop drinking alcohol. Advise people with recurrent acute or chronic pancreatitis not alcohol-related that alcohol might exacerbate their pancreatitis. • When discussing smoking cessation with patients, make them aware of the link between smoking and

chronic pancreatitis and advise people with chronic pancreatitis to stop smoking. For support with this, the guidance refers to the NICE guidelines on the diagnosis and management of physical complications of alcohol-use disorders,3 the diagnosis, assessment and management of harmful drinking and alcohol dependence4 and NICE guidance on stop-smoking interventions and services.5 The guidance goes on to discuss specific advice for both acute and chronic pancreatitis, which both have important nutritional aspects.

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

ACUTE PANCREATITIS

Acute pancreatitis is a condition where the pancreas becomes inflamed over a short period of time. The NHS reported 25,000 people were admitted to hospital with acute pancreatitis in the years 20132014.6 Acute pancreatitis can occur at different severities – mild, moderately severe and severe – and usually resolves in 48 hours if it is a mild-moderate form.7 It is usually caused by alcohol consumption or gallstones; however, the NICE guidance emphasises that we should not assume a person’s acute pancreatitis is alcohol-related just because they drink alcohol.1,7 Specifically looking at nutrition support for acute pancreatitis, the guidance advises the following: • Ensure that people with acute pancreatitis are not made ‘nilby-mouth’ and do not have food

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CONDITIONS & DISORDERS

withheld unless there is a clear reason to do so (eg, vomiting). • Offer enteral nutrition to anyone with severe or moderately severe acute pancreatitis. Start within 72 hours of presentation and aim to meet their nutritional requirements as soon as possible. • Offer anyone with severe or moderately severe acute pancreatitis parenteral nutrition only if enteral nutrition has failed or is contraindicated.1 CHRONIC PANCREATITIS

Chronic pancreatitis differs from the acute form as it is an irreversible and long-term inflammation or fibrosis of the pancreas.8 Chronic pancreatitis can lead to endocrine pancreatic insufficiency, resulting from damage to the endocrine tissue of the pancreatic gland (islets of Langerhans), with failure to produce insulin, causing impaired glucose regulation and diabetes mellitus. Pancreatic exocrine insufficiency (PEI) may also occur from damage to the acinar cells, with failure to produce digestive enzymes, causing malabsorption.8 The NICE guidance discusses general nutrition support, as well as highlighting follow up and the condition’s links to diabetes and cancer. It is necessary to identify those who need to be followed up and what tests are required,1 as 46

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people with pancreatitis are at long-term risk of nutritional problems and diabetes and also have an increased risk of pancreatic cancer. The NICE guidance also notes that pancreatitis is a serious and complex condition, which can have a severe effect on quality of life and may result in reduced life expectancy. The guidance states that, in the past, there has been lack of knowledge on how to manage pancreatitis, which has resulted in clinicians avoiding those with the disease and conflicting advice being offered. The guidance, therefore, aims to enable people with pancreatitis to receive appropriate care, thus improving the outcomes of this difficult condition. Similar to the acute pancreatitis advice, the NICE guidance begins with stating that it should not be assumed that a person’s chronic pancreatitis is alcohol-related just because they drink alcohol. Nutrition support • Be aware that all people with chronic pancreatitis are at high risk of malabsorption, malnutrition and a deterioration in their quality of life. • Use protocols agreed with the specialist pancreatic centre to identify when advice from a specialist dietitian is needed, including advice on food, supplements and long-term PERT, and when to start these interventions. • Consider assessment by a dietitian for anyone diagnosed with chronic pancreatitis. TYPE 3C DIABETES

The guidance also discusses the risk of developing diabetes, known as Type 3 diabetes, as a result of pancreatitis. It states that people with chronic pancreatitis have a lifetime risk as high as 80%, and this risk increases with duration of pancreatitis and if calcific pancreatitis is present. It is advised that: • chronic pancreatitis patients are offered monitoring of HbA1c for diabetes at least every six months; • patients with Type 3c diabetes are assessed every six months for potential benefit of insulin therapy.

This guidance signposts to using the appropriate NICE guidance on managing diabetes for support.9,10 FOLLOW-UP

For patients with chronic pancreatitis and PEI it is advised to: • offer people with chronic pancreatitis monitoring by clinical and biochemical assessment, to be agreed with the specialist centre, for PEI and malnutrition at least every 12 months (every six months in under 16s); • adjust the treatment of vitamin and mineral deficiencies accordingly; • offer adults with chronic pancreatitis a bone density assessment every two years. As patients with pancreatitis have an increased risk of developing pancreatic cancer (the lifetime risk is highest, around 40%, in those with hereditary pancreatitis), annual monitoring for pancreatic cancer in people with hereditary pancreatitis should be considered.1 PANCREATIC CANCER

The NICE guidance on pancreatic cancer in adults – diagnosis and management NG85 – was updated in February 2018.2 A main aim of the guidance was to help improve diagnosis and treatment of pancreatic cancer, as the NHS England ‘Five Year Forward View’11 highlighted that there are often delays in access to diagnosis and treatment for patients with pancreatic cancer. The NICE guidance states that many people with pancreatic cancer benefit from dietary counselling to increase their nutritional intake – this may be in the form of food-first methods and the use of ONS. However, the guidance notes that there is variation in the level and type of information given and the routes through which nutrition is provided, also, that there is uncertainty over what are the most effective interventions and routes for providing nutrition. It was also noted that weight loss is common in patients with pancreatic cancer, both in resectable and non-resectable disease. This is likely due to one or a combination

of the following: reduced dietary intake; malabsorption; post-surgical complications affecting nutritional status; cachexia and hyperglycaemia due to impaired glucose tolerance; or undiagnosed diabetes. Weight loss can be severe and debilitating for the patient and contributes towards the development of loss of muscle mass and reduced muscle function, ultimately affecting quality of life. Interestingly, the guidance states that there is considerable variation in the nutritional input received by people with pancreatic cancer in different parts of the country (and in some cases between local hospitals, or GPs and tertiary centres). This has been reported to be an area of confusion for people with pancreatic cancer, their families and some healthcare professionals, meaning that some people continue to experience symptoms that have a negative impact on their quality of life. Good nutritional input can improve quality of life for people with pancreatic cancer and, potentially, improve their ability to undergo oncological treatment and survival. There is a high incidence of PEI in those with pancreatic cancer. It is again noted that there is significant variation in the amount of specialist information people receive on how to take PERT effectively. This results in some patients continuing to experience the symptoms and consequences of poor digestion and not getting the full benefit of this intervention.2 The concluded recommendations in the guidance for nutrition support are as follows: • Offer enteric-coated pancreatin for people with unresectable pancreatic cancer. • Consider enteric-coated pancreatin before and after pancreatic cancer resection. • Do not use fish oils as a nutritional intervention to manage weight loss in people with unresectable pancreatic cancer. • For people who have had pancreatoduodenectomy (also known as a Whipple procedure – where the head of the pancreas, the duodenum, a portion of the stomach, and other nearby tissues are removed) and who have a functioning gut, offer early enteral nutrition (including oral and tube feeding) rather than parenteral nutrition. 2 www.NHDmag.com March 2019 - Issue 142

F2F

FACE TO FACE Ursula meets: EULALEE GREEN • Pre- and antenatal nutrition expert 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.

• Vitamin D-a-titian • Community health projects leader

The night was cold; the tomato soup was hot. We meet after Eulalee’s day of work at the Portland Hospital (the private maternity hospital in Central London). She seems unsure why I would want to meet up with her. But I had the feeling that she had a story to tell. Here it is. School was not easy, because Eulalee declares she has dyslexia. Subjects she was channelled into by well-meaning teachers were arty and crafty. But after a hospital visit, she was inspired, and declared that she wanted to become a paediatric psychiatrist. Healing and caring for children became the magnet for her motivations. “While thinking about a career, someone told me that nutrition was the basis of all health. This struck me as such an obvious and powerful truth, that I decided I wanted to be a dietitian,” said Eulalee. The more-than-slight barrier was her science qualifications – the lack of. She attended an adult technical college while jobbing and managed to obtain the golden-three science A Levels: Biology, Chemistry and Physics. “Because of my dyslexia, my exam grades were always a bit lower than my course work grades, but I managed to pass,” said Eulalee. She had to leave her home in Manchester to study dietetics and thought London offered the best options. She was anxious about being a bit older and a bit dyslexic. “North London Polytechnic (now London Metropolitan

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

University) were particularly friendly and welcoming, and invited me to come along for tea and chats. So of course this is where I chose to study.” Her first job was a half-year post with the charity, Coronary Prevention Group. They were involved in an occupational health project funded by London Transport, so Eulalee spent a lot of time giving lifestyle and dietary advice to bus drivers and tube drivers. “They were at higher risk of heart disease because they work long shifts and the jobs are sedentary, so it was important to be able to give targeted support on being healthier to these great guys.” Eulalee’s next job was a full-time dietitian post at St Thomas’ Hospital. “The job offered rotations to different departments and community clinics, which I really enjoyed.” She then did several split posts as a paediatric and a community dietitian – and she had a baby. Plus, on a part-time basis, she completed the MSc in Health Promotion at Brunel University for her role in public health. “The MSc dissertation taught me so much about motivations behind health behaviours, and also the really important role of careful language to support and inspire people to better health,” said Eulalee. The smaller theme of Eulalee’s career has been community-based support for children at home requiring enteral feeds. She suggests that caseloads

"It was really important to promote vitamin D supplements to all mothers with infants and our project resulted in greatly improved uptakes”

for dietitians are (too) high and that perhaps the BDA could more assertively critique these situations. The larger theme of her career has been the development of health strategies to support babies and young children. One of her projects was to promote the use of vitamin D supplements in the London Borough of Ealing. “About 50% of the population is Asian or Black, and there were many cases of rickets. There were a few deaths due to hypercalcaemic seizure. It was really important to promote vitamin D supplements to all mothers with infants and our project resulted in greatly improved uptakes,” said Eulalee. Just targeting at-risk groups is one way to achieve results, but Eulalee was now becoming more forceful: blanket policies were usually more successful. If messages were clear and consistent and delivered to everyone, at-risk groups also did better. Another project was promoting greater rates of breastfeeding, to allow Baby Friendly accreditation. “I spent a lot of time with health visitors, to consider ways to support new mothers. But it was a difficult time for the profession for several reasons, including many new duties to support child protection. Surprising allies turned out to be the clinic booking clerks. Friendly casual enquiries about breastfeeding turned out to be the quickest way to identify mothers needing extra support,” said Eulalee. The rates doubled. Eulalee now splits her time between her paediatric post at the Portland Hospital, her community enteral feeds post at the Homerton Hospital and her private work advising on women’s health, especially on pre- and antenatal

nutrition, via her consultancy ‘Family Nutrition Coach’. She has tried to slip out of management roles, because she enjoys small project work the most, and working with patients (rather than mountains of admin). Her on-the-side role is also as current treasurer of the BDA Freelance Dietitians Group. “There are so many sad situations reported by the Child Development Team and I feel that some of the adverse outcomes could be avoided with better preconception and antenatal nutrition,” said Eulalee. She is concerned about the inadequate vitamin D, folic acid and iodine status of many pregnant women. She also feels that weights should be checked at every antenatal appointment, as advised by the Royal College of Obstetricians and Gynaecologists (but in contrast to NICE guidance). The UK government has announced a consultation on mandatory folic acid fortification of flour. Was this good news, I asked her? “Of course,” she said. But many people do not feel it should be done for the benefit of ‘just-thefew’ pregnant women. She thought that a much stronger health message could be about the possible benefits of folic acid in reducing the risk of stroke in the older population. Later that night I had a dream about Eulalee. She showed big biceps and was wearing boxing gloves. Yes, she is a fighter. And yes, she fights for the little ones. And yes, she is a great vitamin D-a-titian. www.NHDmag.com March 2019 - Issue 142

EVENTS & COURSES YAKULT STUDY DAY 2019 Latest insights into the gut microbiota and health: from research to practice 25th June, 8.30am to 4.30pm Venue: Wellcome Collection, London Early Bird: £60/£25 for students (before 31/03/19) Regular: £85/£50 for students (after 31/03/2019) For more information visit: www.hcp.yakult.co.uk/events/158/yakult-studyday-2019

Upcoming events and courses. You can find more by visiting NHD.mag.com

THE ROYAL MARSDEN FOUNDATION TRUST STUDY DAYS: Foundation in Oncology for Speech and Language Therapists 27th June – EVENT ID 680 The Long-term GI consequences of Cancer Treatment 8th July – EVENT ID 798 Swallowing and Communication Rehabilitation for People Diagnosed with Head & Neck Cancer 12th September - EVENT ID 686 For full details please visit www.royalmarsden.nhs.uk/news-and-events/ conference-centre/study-days-and-conferences

NUTRITION AND HYDRATION WEEK 11th to 17th March www.nutritionandhydrationweek.co.uk ADULT TRACHEOSTOMY CARE – ALL YOU NEED TO KNOW 18th March www.royalmarsden.nhs.uk/news-and-events/ conference-centre/study-days-and-conferences/

RECIPE ANALYSIS: MAXIMISING ACCURACY 22nd March On behalf of Nutrition and Wellbeing, Susan Church Nutrition - Leeds Cookery School www.susanchurchnutrition.co.uk/recipe-analysistraining DIABETES UK CONFERENCE 6th to 8th March ACC, Liverpool, www.diabetes.org.uk

dieteticJOBS.co.uk BAND 6 PAEDIATRIC DIETITIAN (1.0 WTE) QUEEN ELIZABETH HOSPITAL, KING'S LYNN Or Band 5 with the opportunity for ‘fast track development’ to Band 6 once agreed competencies achieved (*0.8wte Paediatrics and 0.2wte adult Dietetics). We are looking for an enthusiastic and innovative Dietitian to work as part of a team delivering a specialist paediatric dietetic service to the Queen Elizabeth Hospital. You will be working closely with the Band 8 lead, Band 6 Specialist Paediatric Dietitian and the wider MDT providing a specialist service to both inpatients and outpatients. There would be opportunities to build your dietetic knowledge and skills in Paediatric Diabetes as well as in general paediatrics, food allergy and intolerance, home enteral tube feeding, coeliac disease and neonates. You will provide the Dietetic service to a designated adult ward when required. Specialist clinical skills, a highly professional attitude along with excellent communication skills, organizational skills and a caring and compassionate nature are essential for this post. You would be part of a team of 12.5 WTE registered Dietitians, 3 Dietetic Assistants and 3 secretarial support staff. The Department is based in the Acute Trust, providing the Dietetic service to this Trust and a clinical outreach service to West Norfolk CCG and the adjacent part of Cambridgeshire. We are a supportive department and take pride in the delivery of a quality service to people who come into contact with us. The department encourages CPD and has an established system of support for members of staff. Please contact Susan Patten on 01553 613461 or Sarah Fletcher on 01553 613861 if you would like further information. An application form and job description can be accessed online at www.jobs.nhs.uk. Closing date: 18th March 2019.

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MY TV DEBUT At the beginning of the year, our hospital communications department was contacted by BBC Midlands Today looking for an expert to comment on a story they were running on sugar. So, we were asked if anyone would like to appear on the red sofa for the evening news with Nick Owen. It was a Friday lunchtime, my day off and the last day of the Christmas holidays. I’d never been on TV before and here was a perfect chance – local TV, fairly easy subject (well easier than my usual presentations on inherited metabolic disorders) and I had a couple of hours at home to prepare! I thought I would go for it! The producer of the show called to let me know about the film they had recorded to go with the story and what questions to expect. The segment was only two minutes long, so there wouldn’t be time for a lot of questions. The phone call, however, took half an hour and I felt like I was being sounded out to make sure I could do it! It was very exciting heading into the BBC studios that evening. I met Nick Owen before the show and chatted with the researcher. They had bought some food props for us to talk about. I then had 15 minutes to check out the sugar content of the foods and memorise how many sugar lumps they equated to. Then the time came to put on the mic and head into the studio. I was allowed one piece of paper that I could put on the desk to glance at if I needed to and was told not to look at the camera, only at Nick. And then, the film was rolling and we were counted down to live. The film was about a local boy who had

Louise Robertson Specialist Dietitian

measured out how much sugar each of his family was allowed each day. Every time they ate foods containing sugar they spooned the amount of sugar in that food out of their bowl until they had none left. When it was empty they were not allowed any more sugar that day. It made them understand how much sugar they were eating and where it was coming from. I had to comment on the film and then Nick asked me about the sugar content of the foods on the table. Luckily I remembered all my figures without glancing at my paper. For the last question, Nick tried to catch me out by asking how dangerous sugar is! I calmly told him that sugar isn’t dangerous, but eating too much can lead to obesity and tooth decay! Then it was all over. I did it, no stumbling on my words and I think I got my point across. Best of all I think I actually enjoyed it! I’m so glad the BBC asked for a dietitian to comment rather than an unqualified person. Last year I wrote about how we need to ‘rise above the gloop’, to be heard through the noise of big health influencers. The move is starting to happen with dietitians and registered nutritionists writing books, running podcasts and YouTube channels, running successful social media pages and appearing on TV to voice their expert knowledge. Long may this continue!

Louise is an experienced NHS dietitian who has been specialising in the fascinating area of Inherited Metabolic Disorders in adults for the last 10 years. In her spare time she enjoys running her blog Dietitian’s Life with her colleague and good friend Sarah Howe, playing the cello and keeping up with her two little girls! www. dietitianslife.com

www.NHDmag.com March 2019 - Issue 142

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

the

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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.

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