COMMUNITY
COMMUNITY DIETETICS: IS THE FUTURE LOOKING BRIGHT? (SPOILER – YES, IT IS!) NHS chief executive Nigel Stevens has warned that we need to “get serious about obesity, or bankrupt the NHS”.1 In the UK, we are eating more calories and have become more sedentary than a few decades ago and due to these changes in dietary and lifestyle patterns, chronic diseases including obesity, Type 2 diabetes mellitus, cardiovascular disease, hypertension, stroke and some types of cancers (for example bowel and breast), are becoming increasingly significant causes of disability and premature death.2 The potential burden of chronic disease arising from diet and lifestylerelated causes is huge. Currently, the health service in England spends around 10% of its budget on treating diabetes; 26% of adults in the UK are now classed as obese3 and rates of Type 2 diabetes are rising rapidly worldwide, with increasing incidence in younger people. Alongside this, recruitment of GPs is at an all-time low, with high numbers of experienced GPs set to retire over the coming decade.4 How are we going to manage this increasingly medically complex and chronically ill population? THE WAY AHEAD
The NHS Five Year Forward View was launched in October 2014, with a big focus on prevention of chronic conditions and empowering people to self-manage wherever possible.5 Moving forward from this, the NHS Long Term Plan has set out to ensure that patients have more options, better support and properly joined-up care at the right time in the optimal care
setting.6 The GP Forward View (NHS England 2016)7 builds on the Five Year Forward View with general practice in mind. It describes the extra money going into training more GPs, but goes on to suggest the need to make better use of the wider primary care workforce. In terms of that wider MDT, dietitians often come under ‘AHPs/ therapists and other staff’. We are often not seen as a standalone profession at present, in the same way as doctors and nurses. The British Dietetic Association (BDA) has produced an excellent comprehensive paper that I would recommend reading, titled Dietitians in Primary care8 and also a short leaflet to summarise the impact dietitians can have. Within this document, the BDA proposes a ‘primary care dietitian’ role as an ‘expert generalist’. This role would form an essential part of the general practice team, much in the same way as a practice nurse. It is outdated that we need to see a GP first in general practice. There have been large advances with ‘physio first’ where people will have an appointment with a physiotherapist for their back pain instead of seeing a GP and, regularly, people will see their practice nurse for more routine appointments (including diabetes management). Research from Health Watch has shown that patients do not mind what healthcare professional they see, as long
Alice Fletcher Registered Dietitian within the NHS Countess of Chester NHS Foundation Trust (Community Dietitian) Alice has been a Registered Dietitian for four and a half years working within NHS Community based teams. She is passionate about evidencebased nutrition, cooking, and dispelling diet myths. Alice (occasionally!) blogs about food and nutrition in her spare time at nutritionin wonderland.com.
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COMMUNITY Figure 1: The role of a community dietitian
as it is the ‘right’ person.9 As so many health conditions have a firm link to diet and lifestyle, ‘dietitian first’ should become common place. The BDA has noted that community dietitians have a very important role to play in (see Figure 1): • reducing referrals to secondary care; • managing prescribed medicines; • reducing the need for hospitalisation; • enabling self-care of long-term conditions; • managing use of nutritional borderline substances; • making prevention happen; • reducing demand on GP time. NICE guidelines include dietary manipulation as well as medications for many conditions, with dietary changes often being the first port of call. In Table 1 overleaf, I have outlined some ways in which the team at the Countess of Chester Hospital (COCH) community dietetic service are working towards these goals. VERY LOW CALORIE DIETS FOR TREATMENT OF OBESITY AND TYPE 2 DIABETES
Obesity increases risk of cancer, heart disease, stroke, diabetes, and arthritis, or can make some of these conditions worse. In November
2018, Public Health England announced that very low calorie diets (VLCD) will be trialled in primary care as part of the NHS Long Term Plan, following on from the DROPLET and DiRECT studies, which showed significant and exciting outcomes.10 Across the country, dietitians within primary and secondary care are beginning to support people to follow a VLCD for weight loss, or to induce remission from Type 2 diabetes. This includes work within GP practices in Wrexham (North Wales) and within Hackney Diabetes Centre in London, amongst many others. It is vital that as dietitians we grab this opportunity to use our expertise to support such interventions. DIETITIANS AS SUPPLEMENTARY PRESCRIBERS
Nurses, pharmacists, optometrists, physiotherapists, podiatrists and radiographers can all train to be supplementary prescribers. As of 2016, dietitians have been added to this list11 and this encompasses so much more than just ONS. Prescribing medications in line with NICE algorithms as part of dietetic practice has huge potential in terms of managing chronic diseases in the general population, saving the NHS time and money too. If medications are utilised to manage chronic conditions, this www.NHDmag.com May 2019 - Issue 144
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COMMUNITY Table 1: Countess of Chester Hospital community dietetic service Nutrition support group education for patients and family members • For people referred to the department for noncomplex nutrition support, we have developed group education sessions. • Within these sessions, patients and carers receive an overview of the causes and consequences of malnutrition, food-first approaches and information regarding self-monitoring. • Patients are given their weights and BMIs on a self-monitoring form. Food-first literature and department contact details are also given. • This is a one-off appointment and the onus is placed on the patients and their carers to get back in touch directly with the dietetic department should their weight continue to decline/not increase. Nursing/care home education – nutrition support and MUST training A lot of work has been carried out by a specialist dietitian to improve the detection and treatment of malnutrition within care homes. • Emphasis has been placed on giving care home staff the tools they need to identify those at risk of malnutrition, before they themselves document and implement a measurable food-based plan. • ‘Nutrition links’ from different care homes have volunteered themselves to feedback to the community dietetic department in regard to any difficulties implementing food-based plans so that issues can be ironed out. • Training has moved from care homes themselves to centralised locations and we have found this to be beneficial in terms of attendance and focus on the sessions. It also allows nurses and carers from different homes to meet and learn from each other. • Ultimately, we are aiming for the residential and nursing homes to become much more self-sufficient in terms of malnutrition, so that more dietetic time can be spent on prevention and education regarding malnutrition, with one-to-one assessments utilised for more complex cases. Diabetes group education, 2- to 2.5-hour sessions (inclusive of borderline and Type 2 and gestational) • Group education sessions take place across 10 venues, for those newly diagnosed with a form of diabetes, or as a refresher for others. • These sessions continue to receive excellent feedback from patients. • Sessions allow time to dispel diet myths and empower people to self-manage their condition. • We also highlight that Type 2 diabetes can be well managed or even be put into remission through diet and lifestyle changes, reducing risks of long-term complications. This is hugely important. Home enteral tube feeding (HETF) At COCH there is a strong extended hands-on role of dietitians in HETF care. The HETF specialist dietitian works very closely with our community nutrition nurse, as together they help to keep people in their own homes and can be reactive to emergencies. • A competency-based framework is followed for gastrostomy tube changes/ pH checks and the dietitian regularly changes gastrostomy tubes in patients’ own homes. • EnPlug was launched three years ago, if a tube becomes displaced out of hours and is not an immediate emergency for the patient (for example they can still remain hydrated orally), they can maintain their stoma tract patency until the dietitian/nurse is able to visit them and replace the tube. • Our nutrition nurse can place nasogastric tubes in people’s own home following a risk assessment. This is improving patient care hugely. All of this has undoubtedly reduced the incidence of hospital admissions, and means that two staff can be available at the same time in the community to help resolve tube-feeding based issues. An expert generalist dietitian clinic This is based in a GP surgery and is being piloted by our lead dietitian who is a qualified supplementary prescriber. Paediatric prescribing project This is an ongoing project to reduce inappropriate prescribing of formula milks for cow’s milk protein allergy, amongst other conditions. Oral nutritional supplements prescribing project This aims to reduce inappropriate prescribing of oral nutritional supplements in the adult population. Lipid clinic • A ‘dietitian first’ process runs for patients who have been referred to see a consultant biochemist for consideration of medical lipid lowering medications. • A template is used to assess if dietary lifestyle changes can be made and this information is handed over to the doctor before they assess them. • The department is working on a similar pathway within diabetes management. Irritable bowel disease pathway and dietetic led service We aim to reduce unnecessary tests and referrals into secondary care (ie, colonoscopy) and improve patient outcomes. (Rebecca Gasche, Gastroenterology specialist dietitian has outlined this pathway in detail within a previous NHD article, Issue 140, Dec 2018/Jan 2019).
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COMMUNITY should be alongside counselling for diet and lifestyle changes, not as a replacement. Dietitians can tailor specific diet and lifestyle changes to an individual, signpost to relevant education sessions, assess lifestyle changes made and then commence and monitor efficacy of medications. Greater numbers of complex patients are being discharged from hospital into the care of the GP, eg, patients with kidney disease, pancreatic disease and gastrointestinal diseases such as inflammatory bowel disease. Dietitians are skilled at treating such patients from a dietary point of view, but advanced dietitians trained in how to prescribe could improve the patient experience by allowing patients greater access, convenience and choice. For example, if we suspected a patient to be suffering from malabsorption from possible pancreatic insufficiency, we could prescribe pancreatic enzymes; if they had a high output stoma: loperamide hydrochloride; if their serum magnesium levels became low secondary to this: magnesium sulphate. We would then monitor the outcomes. This would allow GPs more time to see the people beyond the scope of the supplementary prescribing dietitian. Scope of practice is extremely important within supplementary prescribing and patients with any red flag symptoms should be passed over to their GP. The BDA has outlined scope of practice for supplementary prescribers within its extensive guidance document.12 HOW DO WE DRUM UP BUSINESS?
The myth of long wait list times for dietetic input persists, therefore, more time may need to be spent on generating better awareness around our profession and what we can offer. Embedding ourselves within general practice would undoubtedly help this. We need to emphasise that we are forward thinking and innovative, we do not dismiss all new dietary approaches as ‘fads’, and we keep up to date with best practice and emerging evidence. It does appear that the dietetic profession is sometimes seen by some healthcare professionals in the opposite light and we need to work hard to change this. DOCTORS AND NUTRITION IN THE COMMUNITY SETTING
There is a growing interest in food’s role in health and disease from doctors and many
garner a lot of media attention in regards to this. Dr Aseem Malhotra is the author of the book The Pioppi Diet and Dr Rangan Chattergee has written The four pillar plan. Dr Hazel Wallace (aka ‘The Food Medic’) has published two recipe books and has a huge presence online. Dr Rupy Aujla has created the UK’s first ‘Culinary Medicine’ course, accredited by the Royal College of General Practice. There are many TV programmes aired regularly with the likes of Dr Michael Mosely and twin brothers Dr Xand and Dr Chris van Tulleken, who look at how lifestyle and diet can affect the health of the nation. Malhotra and many other doctors advocate a low-carb, high-fat approach to eating. Malhotra himself is lobbying for a change in UK public health guidelines to reflect this, speaking in parliament in February 2019. His public health dietary approach is something at odds with current UK guidelines and the BDA. This can feel both frustrating and deflating for the dietetic profession which should always take individuals as individuals and tailor dietary advice to meet their needs. As I have said in a previous NHD article, we are not chasing people with baguettes! Nevertheless, it’s not ideal that BDA events have previously been sponsored by a company selling ‘breakfast biscuits’ that are up to 26% sugar! This is something that is regularly brought up on social media and will never be forgotten. SUMMARY
• Diet is integral to health and disease, both chronic and acute. • We cannot forget that even at a highly specialist level, dietitians are a lot more cost effective than GPs. • Dietitians are often the link that holds complex health and social care pathways together, especially for older people and those living with long-term conditions. • Dietitians can now train to be supplementary prescribers, and this would allow us to manage people’s multiple conditions more effectively, with a mixture of both diet, lifestyle and medicine. • Expert generalist dietitians should start to become more common place in GP practices - and what a fantastic job that would be! www.NHDmag.com May 2019 - Issue 144
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