Network Health Digest May 2019

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The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

May 2019: Issue 144

FOOD INSECURITY KETOGENIC DIET INTUITIVE EATING GUT HEALTH SHORT BOWEL SYNDROME IMD WATCH

COMMUNITY DIETETICS Pages 19-23

MENTAL HEALTH & WELLBEING

THIS IS HUGE After months of coping with the sleepless worry and heartbreaking cries of her cow’s milk allergy, suddenly, a little moment like this doesn’t seem so little after all.

• PROVEN EFFICACY Hypoallergenic and has been shown to relieve symptoms 1,2 • PROVEN TO BE WELL TOLERATED 96% of infants tolerated Similac Alimentum 3 • APPROVED FROM BIRTH ONWARDS No need to switch formula at 6 months • BEST VALUE Provides cost savings in the prescribing of EH* formulations4 SIMILAC ALIMENTUM. FOR BIG LITTLE MOMENTS.

*Extensively Hydrolysed REFERENCES: 1. Sampson HA et al. J Pediatr 1991;118(4): 520-525. 2. Data on file. Abbott Laboratories Ltd., 2013 (Similac Alimentum case studies). 3. Borschel MW and Baggs GE. T O Nutr J 2015;9:1-4. 4. MIMS, March 2019.

IMPORTANT NOTICE: Breastfeeding is best for babies, and is recommended for as long as possible during infancy.

Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional.

Date of preparation: March 2019 RXANI150142(2)

FROM THE EDITOR

WELCOME This month sees two important awareness weeks, which may have great significance in all of our lives, whether it be at work or within our personal time.

Coeliac Awareness Week takes place between 13th and 19th May and I talk a little more about this in our News section on page 6.

The other key awareness event this month also takes place on the same dates: Mental Health Awareness Week, with the theme for 2019 being ‘Body Image’, an issue that can affect all of us at any age. During the week, the Mental Health Foundation will be publishing new research, considering some of the reasons why our body image can impact on the way we feel, campaigning for change and publishing practical tools. More information on this event can be found at www.mentalhealth.org.uk/campaigns/ mental-health-awareness-week With mental health in mind, our Cover Story from Nikki Brierley focuses on the importance of mental health and wellbeing within the workplace and how the NHS is putting staff wellbeing on their agenda. We also welcome back Emma Berry who explores the relationship between food insecurity, nutrition and mental health.

With an ever-increasing ageing and overweight or obese population, the dietitian’s role in primary care will be vital, working towards our profession being a ‘first port of call’ for patients within GP surgeries and clinics. Alice Fletcher outlines her experience of ensuring dietitians are more accessible in the community and looks at the future for dietetics within the community.

Knowledge is shared in NHD from all areas of nutrition and dietetics. This issue is no exception. Our clinical article from Rebecca Gasche, provides us with information on short bowel syndrome and how best to manage this condition nutritionally. The Ketogenic Research Dietitians Network share an overview and update of ketogenics over the past 100 years

and also highlight the recent findings of a survey they completed throughout Emma Coates Editor 2017. Moving onto Paediatrics, Farihah Choudhry delves into the mysterious Emma has been a dietitian world of the gut microbiota and discusses registered for 12 years, with the increasing evidence around the effect experience of adult of probiotics on the immune function in and paediatric dietetics. children. ‘Intuitive eating’ (buzz word of the month), and how it applies to a clinical setting is what Jessica English focuses on in this issue.

And if that’s not enough, NSPKU Dietitian, Suzanna Ford, along with Dr Ben Green, discusses the current landscape with regards to the PKU ‘diet for life’ in IMD Watch and Gill Hooper provides guidance on a practical food-first approach to nourishment in the elderly living in care homes. Evelyn Newman takes a look at a recent project completed in the Highlands were improvements in the consistency in the rationale for prescribing ONS were achieved.

The food-first approach played a major role in this transformation work.

If you have important news or Don’t forget this research updates to share with NHD, or May issue is digital would like to send a letter to the Editor, only, so you can please email us at download it from info@networkhealthgroup.co.uk our website or view it We would love to online at any time: hear from you. www.NHDmag.com Emma www.NHDmag.com May 2019 - Issue 144

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12 COVER STORY Mental health and staff wellbeing 6

News

Latest industry and product updates

9 F2F INTERVIEW 17 Food insecurity

Impact on mental health 19 Community dietetics

Is the future looking bright?

24 SHORT BOWEL SYNDROME

35 Intuitive eating

Implementation in clinical dietetics 39 IMD watch

Challenge of 'diet for life' in PKU

42 FOOD-FIRST APPROACH 46 Social care

Prescribing ONS in the HIghlands 48 A day in the life of . . .

A diabetes dietitian

29 Ketogenic diets

For epilepsy, past,

present and future

NHS Ayrshire and Arran

32 PROBIOTICS & PAEDIATRIC HEALTH

50 Events & courses

Dates for your diary 51 Dietitian's life

Craving for chocolate

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

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Phone 01342 825349 Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

www.NHDmag.com May 2019 - Issue 144

@NHDmagazine ISSN 2398-8754

Neocate Syneo Help rebalance gut microbiota dysbiosis in infants with CMA with new

NEOCATE SYNEO

1,2,5

THE ONLY AAF WITH PRE- AND PROBIOTICS* clinically proven to bring the gut microbiota closer to that of healthy breastfed infants1,5

Neocate: Fast and effective resolution of CMA symptoms

1-4

This information is intended for Healthcare Professionals only.

Neocate Syneo is a Food for Special Medical Purposes for the dietary management of Cow’s Milk Allergy, multiple food protein allergies and other conditions requiring an Amino Acid-based Formula, and must be used under medical supervision after full consideration of all feeding options, including breastfeeding. *Accurate at time of publication, May 2019 Probiotic Bifidobacterium breve M-16V and prebiotic scFOS/lcFOS blend CMA: Cow’s Milk Allergy AAF: Amino Acid-based Formula 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. De Boissieu D. et al. J Pediatr 1997; 131(5):744-747 4. Vanderhoof JA. et al. J Pediatr 1997; 131 (5):741-744 5. Fox et al. Clin Tranl Allergy. 2019;9:5 Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ

www.neocate.co.uk If you would like to order a product sample to be delivered directly to a patient, please visit www.nutriciaproducts.com/samples

NEWS CLINICAL COELIAC AWARENESS WEEK 13TH-19TH MAY 2019 Coeliac UK’s annual awareness campaign returns this month. This year the theme focuses on diagnosis awareness, highlighting the need for more people to ask themselves the question: “Is it coeliac disease?” From 13th-19th May 2019, Coeliac UK are asking everyone to share this message and reach out to people who may not be aware that their symptoms could be undiagnosed coeliac disease.

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

To book your company's

product news for the next issue of

NHD call

01342 824073

How can we all support the campaign Coeliac UK have lots of ways in which you can support this campaign. Here are just a couple of ideas to get you started: • Create a Coeliac UK Awareness Week space, or information point at your workplace. It’s an ideal way to meet and speak to people about coeliac disease, helping to raise awareness and get more people diagnosed.

• We all love a bit of cake, so throwing a gluten-free tea party in your local area, department, or hospital is a great way to raise awareness. Coeliac UK have various leaflets and posters available to use at an event like this. You can register for packs on their website: www.coeliac.org.uk/get-involved/coeliac-uk-awarenessweek-2019. Don’t forget to take photos and share them on social media.

Raising awareness on social media Over the course of the week, Coeliac UK will have plenty of social media posts. They are calling for everyone to share these posts across Facebook, Instagram and Twitter to reach as many people as possible and highlight the symptoms of coeliac disease. If you blog, or write on social media, why not share something this month about coeliac disease? If you are doing anything at all to support the campaign, share with the hashtag #IsItCoeliacDisease Help get people diagnosed Coeliac UK have an online assessment that people can complete to tell them whether they should be tested for coeliac disease. This can be shared on social media (#IsItCoeliacDisease) and you can share the resource by word of mouth too!

Whatever you can do to join in this month’s campaign, you will be helping to reach more people who need to know that their symptoms could be undiagnosed coeliac disease.

Campaign packs are available and you can register for one at www.coeliac.org. uk/get-involved/coeliac-uk-awareness-week-2019

UPDATE ON ADVERTISING RESTRICTIONS FOR PRODUCTS HIGH IN FAT, SALT AND SUGAR (HFSS) Further to our News report in the February issue on the government’s open consultation on restricting the promotion of HFSS foods in a bid to reduce childhood obesity, they are now asking for views on two documents: the consultation document outlining their proposals and the impact assessment considering what the costs to businesses and health benefits would be.

Have your say by visiting: www.gov.uk/ government/consultations/further-advertisingrestrictions-for-products-high-in-fat-salt-and-sugar The consultation is open until 10th June 2019.

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NEWS INTERNATIONAL SURVEY ON CARE RECEIVED BY OBESE PATIENTS A new international survey, the largest of its kind, shows that 8 in 10 people with obesity believe it is their sole responsibility to lose weight. The study also found that people wait six years after initial weight loss struggles before speaking to their healthcare professional (HCP).

ACTION IO (Awareness, Care, and Treatment In Obesity MaNagement – an International Observation), surveyed over 14,500 people with obesity and nearly 2800 HCPs from 11 countries in five continents.

The objectives of the ACTION IO survey were to identify perceptions, attitudes, behaviours and potential barriers to effective obesity care. Results from the survey highlight that: • 71% of HCPs in the survey believe that obese patients are not interested in losing weight, while only 7% of those who are obese said they are not interested, illustrating a clear gap in perception regarding interest to lose weight; • 81% of people surveyed had made at least one serious weight-loss effort in the past, while HCPs believe only 35% of their patients had done so.

ACTION IO has been published in Diabetes, Obesity and Metabolism Today, Monday 29 April. www.onlinelibrary.wiley. com/doi/10.1111/dom.13752

COCHRANE REVIEW - THE EFFECT OF A HEALTHY LIFESTYLE

By Manu5 - www.scientificanimations.com FOR WOMEN WITH POLYCYSTIC OVARY SYNDROME Polycystic ovary syndrome (PCOS) is a very common condition affecting 8%-13% of women.

Being overweight worsens all clinical features of PCOS. The condition affects quality of life and can worsen anxiety and depression either due to its symptoms or due to the diagnosis of a chronic disease.

The Cochrane review considered evidence from a variety of studies on the effects of lifestyle interventions on reproductive, anthropometric (body measurement), metabolic and quality of life outcomes in women with PCOS. The review concludes that lifestyle interventions may improve the free androgen index (FAI), weight and BMI in women with PCOS, but the effect of lifestyle intervention on glucose tolerance in uncertain. The benefits of diet and exercise for weight loss have been demonstrated in women with PCOS in low-quality studies, but this remains to be confirmed in higher-quality studies. The review recommends that the effect of various intervention characteristics, including intervention type, duration, intensity and other aspects of implementation on various outcomes should be considered in future trials.

Read the full review here: www.cochranelibrary.com/cdsr/ doi/10.1002/14651858.CD007506.pub4/full

The Ketogenic Dietitians Research Network is a group of paediatric and adult ketogenic dietitians and researchers. The aims of the group are to: • provide a support network for dietitians to undertake ketogenic diet (KD)-related research; • share practice and research ideas between ketogenic centres; • seek funded research time for dietetic-led projects; • promote evidence-based practice by publishing results from our projects, and through sharing and review of relevant journal articles.

If you are a dietitian or dietetic support worker working in ketogenic-related clinical practice, academia or industry and are interested in joining the group, or collaborating with us, we would love to hear from you! We also offer Associate Membership for dietitians not currently practicing in ketogenics and for other healthcare professionals.

Please contact Dr Natasha Schoeler: n.schoeler@ucl.ac.uk. www.NHDmag.com May 2019 - Issue 144

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Call for Research Reviews from NHD and British Lion eggs Network Health Digest (NHD) and British Lion eggs surveyed readers earlier this year about eggs and found that there’s still much about this nutrient-packed food that healthcare professionals are unclear about.

To help educate your peers, we would like your original research reviews on the role of eggs in the diet. We are looking for fully referenced articles discussing two key themes: 1. Understanding the fat content and calories in eggs, as well as additional nutritional benefits they offer.

2. Egg safety, especially in relation to babies and older people, and allergy.

The best article will be published in NHD later this year and the winning author will

WIN £500 WORTH OF SHOPPING VOUCHERS.

Emma

Entries will be judged

by NHD Editor Emma Coates RD and Dietitian and Health Writer, Dr Carrie Ruxton.

Carrie

Please email NHD here . . . for a ‘Contributor template’ and further guidance on submissions.

We look forward to receiving your entries.

For more information on eggs please visit www.egginfo.co.uk For the terms and conditions click here . . .

Deadline for submission Monday 1st July 2019

F2F

FACE TO FACE Ursula meets: KATE GODDEN • Global nutrition expert • Consultant on food security • Nutrition lecturer

We arranged to meet at a lovely bright café in North London. I was early, and so spent some time looking at the wallwide map. Huge islands that I had never heard of, took my notice: Novaya Zemlya, Svalbard, Ellesmere and Baffin islands. By glorious serendipity, the large map was the most perfect backdrop for my date with Kate.

I had been looking to interview someone who had worked as a nutritionist for a famine relief agency, but numerous calls to humanitarian aid charities came to nothing. When I met Kate at a meeting, she became the fly who flew into my web. She was just what I had been looking for: someone who applied nutrition science to decisions, not in a cool calm office, or clinic, but in the chaos of a loud and hot and dusty tent.

Kate always loved food, but her science skills proved better than her cookery skills. She graduated with a BSc in Physiology and Nutrition from the University of Southampton in 1985.

Here comes the clue to her future career: “It was a great annoyance to me that graduation day clashed with the huge Live Aid concert at Wembley, which was a fundraiser for famine relief in Ethiopia,” said Kate. After a gap year of travel and jobbing, Kate decided that dietetics offered the perfect combination: science, talking about food and a good chance of a job. She attended the post graduate dietetics course in Leeds and in 1988 she attached the letters ‘RD’ to her name.

Ursula meets amazing people who influence nutrition policies and practices in the UK. For two years she worked as a basic grade dietitian in London. She enjoyed the work, other than the constant coding required for monitoring each patient encounter or work activity. “It was the early days of computer systems, which was so time-consuming,” said Kate. It seems Kate wanted more excitement in her career.

The charity Voluntary Service Overseas was looking for nutritionists to go to North Central China. After a threeweek language course in Beijing, Kate arrived in the mainly Muslim province of Ningxia. She was there to teach nutrition at an agricultural college, but was always at the mercy of her interpreter: was what she was saying the same as what her students were hearing? She managed to find the contact details of someone who worked at the Food and Agriculture Organisation (FAO) and requested some Chinese language nutrition books. She was surprised and delighted when a huge package of fantastic resources arrived.

Kate returned to London and completed a one-year MSc degree in Human Nutrition at the London School of Hygiene and Tropical Medicine. She was now battle ready to work in the areas of chaos and need. Malanje, in Angola, was being held siege and the charity Medecins sans Frontier (MSF) was providing emergency aid to the local population. “This really was the extreme end of a crisis and there were many thousands of starving people,” said Kate. She was responsible for setting up the feeding stations for the

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

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F2F

“You knew that you could never solve all the problems you wanted to help with.

But you also knew that you were making a big difference . . .”

Children at Malanje in Angola

under-fives. All children were assessed and the severely undernourished ones obtained the refeeding porridge (made from corn-soya blend, sugar, dried skimmed milk and vitamin A fortified vegetable oil.) Supplies were flown in and Kate could easily calculate stock levels by counting planes and multiplying by 20 tons. There was a mixture of kwashiorkor and marasmus presentations, often within families.

But on refeeding, children with kwashiorkor quickly lost fluids and their puffy faces and pot bellies. Kate commented that, “Boys are worse affected by undernutrition than girls. Historically protein boosting was thought to be most effective for treating wasting. Now it is all about providing energy (from a balanced mix of nutrients).” There have been many developments in the delivery of food aid over the last 20 years, and I mention the proprietary peanut paste Plumpy’Nut®. “It is widely used and it works,” said Kate. “But it is an expensive and profitable product, and it is a shame that cheaper local products are not used for refeeding projects.”

From observing film snippets of famine relief, I always found the constant weighing of starving children irksome: it seemed a fussy and unnecessary procedure for the obvious condition.

But Kate explained, “This is really important to identify the more extreme conditions, which are not always obvious, and to monitor the progress of groups. For example, it helped us to identify poor results in one of the four feeding sites in Malanje; we found this was due to more aggressive guards controlling access. Over the period of MSF 10

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intervention, severe wasting in young children went from 36% to 12%, and such data is essential to support decisions and further funding.”

It must have been so difficult to cope with the daily traumas and miseries. “You knew that you could never solve all the problems you wanted to help with. But you also knew that you were making a big difference,” said Kate. And all around were observations of dignity and kindness.

Her next job was in Kandahar in Afghanistan. She was there to do survey work to monitor nutrition status. “Dealing with local leaders (Taliban) was always very difficult and frustrating and the physical environment was extreme: the dry winds were so hot and fierce, it was like being next to a hairdryer,” she said.

But day-to-day encounters with Afghani male colleagues and women and children were always a great pleasure.

Kate held many senior project posts in many countries and, increasingly, nutrition was but one of her many responsibilities. With marriage and children came the decision to move back to the UK. She is now a freelance consultant to many government and NGO clients and advises on emergency and development feeding projects.

She explains Scaling Up Nutrition (SUN) projects to me, as I am sure she explains equally well to students at the University of Westminster (where she also works as a part-time lecturer on the Global Nutrition course).

As we left, I noticed Kate’s very pale translucent skin. Was it the white shimmer from her halo?

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

COVER STORY

MENTAL HEALTH: THE IMPORTANCE OF STAFF WELLBEING Nikki Brierley Specialist Dietitian and CBT Therapist Nikki has been a HCPC registered Dietitian for over 10 years and is also a BABCP accredited CBT Therapist. She works in a dual role within the Adult Community Eating Disorder Service at Cheshire & Wirral Partnership NHS Foundation Trust. She also works privately, providing one to one and group support.

REFERENCES Please visit the Subscriber zone at NHDmag.com

There is good evidence that happy staff are more compassionate and provide safer care. To be best placed to meet the needs of our patients/clients, we need to prioritise our own mental health and wellbeing and provide ourselves with care and support too.1 There is currently a national focus on productivity and the need to prioritise and increase the level of investment in mental health. The government review, Thriving at Work summarises the evidence and makes a very clear case for the value of improved workplace mental health and wellbeing.2 The review highlights the financial and human cost of mental health problems at work, with approximately 300,000 individuals with mental health difficulties leaving their jobs each year.

There is a large estimated cost to employers associated with poor mental health in employees (£33 to £42 billion/ year), due to loss of productivity, sickness and staff turnover. There is a cost to the government also (estimated at £24 to £27 billion/year), which includes benefits, reduced tax revenue and the cost to the NHS. The largest cost, however, appears to be on the economy as a whole, with an estimated £74 to £99 billion/year lost due to reduced output.2 WHAT IS MENTAL HEALTH AND MENTAL WELLBEING?

Mental health and mental wellbeing can be difficult to define and can be interpreted differently by groups and individuals. The WHO describes good mental health as ‘a state of wellbeing, in which every individual realises his or her own potential, can cope 12

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with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’.3 Similarly, mental health can be described as a state of being that is not only free of mental ill health but encompasses a broader context of social, emotional and physical wellness.1 Mental health and mental wellbeing are also observed as dynamic, in that they are changeable from moment to moment, day to day, month to month and year to year.

Good mental health and wellbeing are recognised as being fundamental to physical health, relationships, education/training, work and in reaching our potential.4 They are also associated with a range of better outcomes, regardless of age and/or background (see Table 1 overleaf).

MENTAL ILLNESS

Poor mental health can lead to illness and mental ill health is very common, with one in four adults experiencing problems throughout their lives and many more experiencing mental health difficulties.

Depression, anxiety disorders and phobias are common, with a UK prevalence of ~15%.6 Like physical health, mental health involves a complex interaction between the individual (their genetic, biological, neurodevelopment and other fundamental attributes) and

This material is for healthcare professionals only.

DO MORE THAN JUST MANAGE COW’S MILK ALLERGY: HELP GIVE HER THE ABILITY TO PROTECT HERSELF FROM FUTURE ALLERGIC MANIFESTATIONS1† ONLY NUTRAMIGEN WITH LGG® CAN

TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY

†

Versus Nutramigen without LGG®.

Reference: 1. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913.

Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional.

IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated.

Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland.

Date of preparation: September 2018 UK/NUT/18/0060i

HEALTH & WELLBEING Table 1: Associated benefits of improved mental health and mental wellbeing5 Improved physical health and life expectancy

Reduced risk of suicide

Better educational achievement

Increased enjoyment rates and productivity

Increased skills

Reduced antisocial behaviours and criminality

Reduced health risk behaviours (ie, smoking and alcohol misuse)

Higher levels of social interaction and participation

Table 2: Mental health core standards2 Produce, implement and communicate a ‘mental health at work’ plan.

Provide employees with good working conditions and ensure a healthy work-life balance and opportunities for development.

Develop mental health awareness among employees.

Promote effective people management through line managers and supervisors.

Encourage open conversations about mental health and the support available when employees are struggling.

Routinely monitor employee mental health and wellbeing.

their environment. As such, there are many opportunities to reduce the risk.

The public health white paper, Healthy lives, healthy people7 was the first strategy to give equal weight to both physical and mental health by recognising the role that mental health plays in being central to the overall quality of life.

With the ambition of mental health achieving an equal footing with physical health, NHS England published a 10-year forward view, with the aim of transforming mental health services by 2020.5 The Mental Health Task Force also published a five-year forward view, stating that mental health services are to benefit from additional investment of £1 billion/year by 2020/2021.

MENTAL HEALTH IN THE WORKPLACE

A positive employment experience, where an individual feels supported and valued, can help to promote good mental and physical health. Recommendations to promote a positive employment experience include: • creating a supportive environment that allows employees to be proactive to protect and enhance their own health and wellbeing; 14

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• developing policies to support a workplace culture that respects a work-life balance.2

Conversely, a negative employment experience increases the risk of a reduction in both mental and physical health. Factors that are recognised as affecting mental and physical health in the workplace include: • fear of being judged, • stress, • lack of confidence and so an inability to disclose any problems, • not being able to face the stigma, as mental health issues are seen as a ‘weakness’.

It is recognised that most individuals experience three phases at work – ‘thriving, struggling, or ill and possibly off work’ – and can move between these at different times.2 Worryingly, whilst figures suggests overall sickness rates have fallen by 15-20% since 2009, mental health sickness appears to have increased ~5%, and is currently one of the largest causes of sickness from work in the UK.2 It is suggested that that there are currently

HEALTH & WELLBEING

The Royal College of Nursing reports that 49% of staff have gone to work when unwell with stress and mental ill health problems and 79% of staff thought that staffing levels were not sufficient to meet patients’ needs.

‘significant mental health challenges at work’ and in order to address this, it is suggested that mental health core standards are implemented2 (see Table 2 opposite).

If work-based stress is identified, NICE Guideline 139 recommends that six management aspects are considered and addressed: 1 Demands – work load, work pattern, work environment 2 Control – how much say the employee has in the way they do their work 3 Support – organisation, line manager and colleagues 4 Relationship – promoting positive working to avoid conflict 5 Role – if the employee understands their role 6 Change – how change is managed and communicated

• The Royal College of Nursing reports that 49% of staff have gone to work when unwell with stress and mental ill health problems and 79% of staff thought that staffing levels were not sufficient to meet patients’ needs.

• One in three NHS workforce have felt unwell due to work-related stress and one in two staff members have attended work despite feeling unwell.

• 350,000 staff left the NHS for reasons other than retirement over the past five years.

• The additional cost in this deterioration in staff retention is approximately £1 million/ per annum.

• Work-life balance is reported as a factor in 13% of NHS leavers (approximately 45,000 over a five-year period).

IN THE NHS WORKPLACE

Health Education England has recently published a report entitled: NHS Staff and Learners’ Mental Wellbeing Commission,10 which suggests that there is sufficient evidence to indicate that the NHS could do a much better job in supporting staff and that there is a real need for action to change the current risk of workplace stress, exhaustion, overwhelm

There are some startling facts and figures reported regarding the NHS working environment, including the following:10 • The Royal College of Physicians reports that 84% of doctors believe the workforce is ‘demoralised’, with 80% worried about the ability to deliver safe patient care.

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HEALTH & WELLBEING and burnout. It is recommended that primary interventions should seek to remove the source of distress and that these interventions yield the greatest effect on wellbeing, but require structural change in the workplace/ organisation. Secondary interventions aiming to increase an individual’s resilience and capacity to cope, are viewed as of limited benefit if primary interventions are not also in place (ie, training individuals to be resilient in a system that doesn’t support wellbeing will not effectively solve the problem).10 At the 2018 NHS International Practitioner Health Summit, entitled 'The Wounded Healer', Simon Stevens (NHS England’s Chief Executive) announced national funding to prioritise NHS doctors suffering from mental health problems, recognising that, “ultimately it will be patients and not just their doctors who will benefit”.

There is also an NHS workforce implementation plan underway which is due to be published later this year as part of the NHS Long Term Plan that was published in January.11 The Long Term Plan suggests a new deal for staff, whereby all staff should feel supported, valued and respected. The Plan goes on to suggest that increased flexibility, enhanced wellbeing and career development is made available, alongside efforts to prevent discrimination, violence, bullying and harassment. It is hoped that this will allow the NHS to become a ‘consistently great place to work’.

SUMMARY

Mental health and mental wellbeing are recognised as a fundamental part of overall health and great efforts are being made to place mental health on an equal footing with physical health. It is now well evidenced

and documented that the mental health of healthcare professionals impacts on patient care, with positive mental health associated with better patient outcomes. Reduced mental health in workplace settings appears to be increasing and the human and financial cost of this is significant.

The reported difficulties within the NHS have recently been acknowledged (~38.4% of staff reporting to have felt unwell due to work-related stress), as has the responsibility of the NHS to ‘lessen the mental health impact on staff resulting from the work they do’.10 Recommendations have been published to improve working environments and it is hopeful that primary interventions to reduce workplace/ organisational factors that are causing distress will be implemented.

Most individuals who work within the healthcare environment do so due to a desire to help, care, support and/or heal others.

What is, unfortunately, now very evident is that sometimes this work can have a negative impact on health and wellbeing and that current working environments can further increase this risk. It seems essential that we recognise that working within healthcare can be challenging and that, as dietitians, our own mental and physical wellbeing needs to be protected; not only for our own benefit but also for our patients.

It seems imperative that the values we seek to achieve for our patients (ie, kindness, compassion and professionalism) are the same values we demonstrate to ourselves and each other. Our awareness of the importance and value of promoting and protecting positive mental health and wellbeing needs to extend beyond our patients to ourselves, our colleagues and the wider workforce.

Mental Health Awareness Week 13th to 19th May 2019 www.mentalhealth.org.uk/campaigns/mental-health-awareness-week

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MENTAL HEALTH AND FOOD INSECURITY

CONDITIONS & DISORDERS

Food insecurity is a serious issue across the UK and adults and children alike are living without secured access to food.1 Not having access to food, or worrying about having food to eat, can impact on mental health. This article will explore the relationship between food insecurity, nutrition and mental health.

Food insecurity has different degrees of severity,1 ranging from mild insecurity, which is categorised as worrying about having food to eat, all the way up to severe food insecurity, which involves experiencing hunger due to not having enough food to eat.1 Depression and anxiety are two of the most common mental health problems, with surveys showing that 19.7% of adults display symptoms2 and research has been carried out linking mental health conditions and nutrition.3 Food insecurity is continuing to rise in the UK, with more families struggling to afford food.1 This can result in families skipping meals, or reducing the amount of food that they eat and even relying on emergency food provisions from food banks.1 All these things will impact on the nutritional wellbeing of individuals, as, often, cheaper foods are likely to be more processed and contain less fresh produce.4 FOOD BANKS

Understandably, when individuals are struggling to afford food, their focus is on cost and not on the nutritional value of the food they are buying. For those who might choose to use a food bank, nutritional value of items will depend on what’s given to them. Food banks rely on donations and their parcels are designed to provide enough food for three days.6 Parcels will often contain a mixture of tinned foods, cupboard staples such as rice, and long-life products such as UHT milk.6 They can also include non-food items such as toiletries.6 The Trussell Trust, providing a network of food banks in the UK, released a nutritional analysis report in April 2018, with information on their

emergency food parcels, to determine if they met the nutritional guidelines.7 The report compared the nutrition of a hypothetical food parcel developed from the Trussell Trust’s national ‘pick list’ against food parcels collected from five London food banks.7 The report found that, generally, the food parcels exceeded the nutritional requirements for three days, with the exception of vitamins D and E. The food parcels were high in sugar and salt, exceeding the current UK recommendations. However, removing items such as fruit juice from the parcel to combat this, resulted in a decrease in other vitamins and minerals, such as vitamin C. High levels of salt were not due to any one particular food provided in the parcel, but the report suggested that this is likely to fall in future, as food manufacturers begin to decrease salt in their foods in line with ongoing UK initiatives.7 It was acknowledged too, that there was a lack of fresh fruit and vegetables in the food parcels, but including fresh produce would carry its own problems, such as risk of spoilage and requiring people to have access to refrigeration.

Although these food parcels provide an important source of nutrition for individuals in crisis, the Trussell Trust’s report acknowledged that there were areas which could be improved.7 There are also numerous food banks that are operated outside of the Trussell Trust, which may not have the same nutritional offerings as their own food parcels.

Emma Berry Associate Nutritionist (Registered) Emma is working in Research and Development and is enjoying writing freelance nutrition articles.

REFERENCES Please visit the Subscriber zone at NHDmag.com

THE LINKS BETWEEN NUTRITION AND MENTAL HEALTH

It is well established that nutrition and mental health are linked, with food www.NHDmag.com May 2019 - Issue 144

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CONDITIONS & DISORDERS insecurity having a powerful impact. The Trussell Trust released a report on Disability, Health and Hunger in January 2018,5 highlighting that 89% of food banks surveyed reported mental health issues amongst people who had been referred to them.

Although not all individuals who are food insecure will use food banks, this report does provide strong evidence that food banks should provide mental health support or advice to those in need. Many food banks are already providing this.5 Research has suggested that nutrition and diet can play a role in preventing or reducing mental health symptoms.3 It is clear too, that a diet with more processed foods can increase the risk of mental health symptoms.3 Although the relationship between nutrition, food and mental health is complex and requires further research, the links are important to understand.

There are strong emotional ties to food and our choices are not related to nutrition alone.

Many individuals eat emotionally for comfort when upset, often choosing processed foods high in sugar or fat.8 It would be interesting to investigate whether some individuals choose processed foods as a result of already coping with mental health symptoms. They may choose certain foods for a number of other reasons, not just emotional comfort. This could perhaps be a cycle, whereby one of these things leads to the other. This may be increased in individuals who are food insecure, as they may not have the choice to eat fresh foods due to cost, or may have limited storage facilities available to them. Instead, they may be purchasing processed foods, or receiving food parcels that may contain processed foods.

As previously stated, many individuals who are food insecure will suffer from mental health symptoms.5 Children and young adults who have suffered from food insecurity are more likely to be at risk of obesity,9 mental health symptoms and chronic health conditions.10 Therefore, reducing food insecurity could have a massive impact on our current population’s health and also on the health of our population in the future.

REDUCING FOOD INSECURITY

There are many challenges when it comes to reducing food insecurity, improving access to affordable nutritious foods and providing 18

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appropriate support for mental health symptoms.

If we were to reduce food insecurity then more individuals should have access to nutritious foods and there may be less individuals with mental health symptoms as a result of being food insecure. There are a number of ways that we could work towards these goals, but resources are needed to support change.

Until recently, the UK government has resisted measuring food insecurity, unlike other countries; instead, organisations like the Food Foundation have provided reports.1 However, a measure of food insecurity is due to be introduced in the UK,11 which will hopefully be the start of a government-led programme to reduce food insecurity in this country.

MENTAL HEALTH SEVICES

Whereas food insecurity has still to be tackled across the UK, there have been significant campaigns to reduce mental health stigma and improve awareness of mental health symptoms.

These campaigns are extremely important to encourage individuals to get help if they need it, without worrying about the risk of discrimination.

Although individuals who use food banks should have access to support if they need it, not all individuals who are food insecure use food banks. Having free, accessible mental health services and support is extremely important for this group (and the population as a whole).

Mental health services can be accessed through the NHS, but also via a number of charities such as Mind UK, Samaritans and the Mental Health Foundation. These services are vital in ensuring that a range of services are accessible and provide support for people in need.

CONCLUSION

There is a lot of excellent work going on to improve food insecurity, improve access to nutritious foods and provide appropriate support for mental health needs. A lot of this work comes from the voluntary sector, but, hopefully, with an increasing amount of support from the government, this work will continue to grow, resulting in a larger impact. This would improve the lives and experiences of those in substantial need.

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.

REFERENCES Please visit the Subscriber zone at NHDmag.com

www.NHDmag.com May 2019 - Issue 144

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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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CLINICAL

SHORT BOWEL SYNDROME

Rebecca Gasche Specialist 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.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Short bowel syndrome (SBS), where a patient is left with a shortened length of bowel following surgery, is a rare but serious condition. It can leave patients with chronic malabsorption and carries a number of nutritional consequences.1 It is important that healthcare professionals understand the causes, complications and management of SBS, so that the correct advice is provided for this patient group.

To understand SBS we should first understand the bowel itself. The bowel consists of the large and small intestine.

The large bowel (colon) consists of the caecum, ascending colon, transverse colon, descending colon, sigmoid colon and rectum, and its functions include: the absorption of water, electrolytes, short-chain fatty acids, moving colonic contents towards the rectum and eventually, defaecation.2 The small intestine consists of the duodenum, jejunum and ileum. The average length of the small intestine is 6.9m, with a surface area of 200-500m, due to the addition of mucosal folds, villi and microvilli.3 Its main functions are to complete digestion of food and absorb fluid, electrolytes and nutrients.

90% of fluid from oral and exocrine secretions is absorbed in the small intestine.2 WHAT IS SBS?

SBS can be defined as the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balances, when on a normal diet, as a result of said occurrences4 and is classified if a patient has less than 200cm left of their small intestine.5 Conditions which may lead to SBS include: • Crohn’s disease (a form of inflammatory bowel disease); • volvulus (twisting of the intestine, which cuts off blood flow); • intestinal ischemia (lack of flow to blood vessels in the intestine); 24

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• birth defects, including: necrotizing enterocolitis (NEC – inflammation/ infection that damages bowel tissue in premature infants), intestinal atresia (where the intestines have not been formed correctly), gastroschisis (intestines develop outside of the body); • surgeries/treatments, such as surgery to remove cancer, radiotherapy, bariatric surgery complications, or traumatic injury.1 SBS may result in patients having anastomosis (where the parts of the intestine are reconnected after the diseased portion is removed), or a stoma (where the end of the intestine is brought to the abdomen to allow waste products into the stoma bag attached).

The surgeries that result in <200cm small bowel and, therefore, SBS, are jejunocolonic anastomosis (where the jejunum is reconnected to the colon – see Figure 1), end jejunostomy (jejunum is brought to the abdomen and a stoma is formed – see Figure 2) and jejunoileal anastomosis (parts of the jejunum and ileum are removed and the intestines reconnected – see Figure 3).5 COMPLICATIONS OF SBS

The main nutritional consequence of SBS is the ability to maintain fluid and electrolyte balances. For patients with parts of the jejunum and ileum removed, digestive and absorption function is significantly reduced, and

CLINICAL for those with the colon also removed, additional fluids and electrolytes will be lost.6 Other complications may include: • vitamin and mineral deficiencies; • small intestine bacterial overgrowth (SIBO); • kidney stones (due to reduced absorption or calcium, fats and bile salts); • acidosis (as a result of undigested carbohydrates in the large intestine producing lactic acid); • nausea and vomiting.

Figure 1: Jejunocolic anastomosis

For patients who require parenteral nutrition (PN), this comes with its own risks, such as bloodstream infections or liver/kidney problems.1

FLUID AND ELECTROLYTE BALANCE MANAGEMENT

To help manage fluid and electrolyte balance, fluid restrictions and rehydration solutions can be used. The ESPEN guidelines recommend that those who have borderline dehydration, or sodium depletion, use a sodium oral rehydration solution to replace stoma sodium losses, as well as restricting hypotonic fluids (water, tea, coffee, or alcohol). The addition of salt to meals may also help with sodium levels.5 Evidence suggests that restricting hypotonic fluids to <1500ml per day can reduce intestinal losses by 23%,7 and that including an oral rehydration solution containing 90mmol/L sodium, 20g glucose, 3.5g sodium chloride and 2.5g of sodium bicarbonate, is advised.4

Figure 2: End-jejunostomy

Figure 3: Jejunoileal anastomosis

NUTRITIONAL MANAGEMENT

Patients with SBS may have a normal diet, or use enteral nutrition or PN to supplement this, or as their sole nutrition source. The length of bowel remaining and area of resection often dictates which nutritional support is required: • 100-200cm small intestine may be managed with oral diet and fluid management.

• <100cm jejunum requires long-term parenteral fluid and electrolyte replacement.

• <75cm requires long-term PN, fluid and electrolyte replacement.

• <50cm jejunum plus colon requires longterm total parenteral nutrition (TPN), fluid and electrolyte replacement.8 www.NHDmag.com May 2019 - Issue 144

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CLINICAL Table 1: Vitamin and mineral supplements for patients with short bowel syndrome12 Vitamin A

10,000-50,000 units daily

Vitamin B12

300g subcutaneously monthly for those with terminal ileal resection/disease

Vitamin C

200-500mg

Vitamin D

1600 units DHT daily; may require 25-OHor 1,23 (OH2)-D3

Vitamin E

30 IU daily

Vitamin K

10mg weekly

Iron

As needed

Selenium

6-100g daily

Zinc

220-440mg daily

Bicarbonate

As needed

Table 2: Recommendations to aid digestion for patients with SBS1 Chew all food thoroughly: • Try for about 40 chews per bite Eat smaller meals more often: • Up to six to eight smaller meals each day • Space each meal out over the course of the day • Eat the most nutritious foods first

Studies suggest that as patients with SBS lack areas of absorption, their total energy and protein intake is around two thirds of their oral energy and protein intake. For this reason, a diet which compensates for this is recommended: 3060kcal/kg/day and 0.2-0.25gN2/kg/day.5,9-11 Polymeric feed is recommended for those being enterally fed, as it has been suggested that nutrient absorption is similar when compared with elemental feeds, but are generally better tolerated, less costly and may better enhance intestinal adaption.5 For patients with a preserved colon, a diet higher in complex carbohydrates and lower in fat, but including medium-chain triglycerides, may be of benefit. However, deficiencies in fat soluble vitamins A, D, E and K and fatty acids should be monitored.

For patients without a colon, the fat:carbohydrate ratio is deemed to have less importance.5 The addition of soluble fibre to enhance intestinal absorption is not recommended, neither is removal of lactose unless a lactose intolerance has been confirmed. The ESPEN guidelines also document that dietary management should be guided by a dietitian who is an expert in this field.5 26

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Limit fluids with meals: • Drink half a glass of fluid (4oz) or less at each meal • Stick with isotonic beverages, like oral rehydration solutions Separate solids and liquids at meals: • Eat solid foods first, as they slow down digestion

Each patient’s dietary advice will vary, depending on their initial diagnosis, exact surgery and symptoms following this. However, the recommendations in Table 2 may help to aid digestion on a general basis for patients with SBS. ONS/MICRONUTRIENTS

A patient’s ability to absorb nutrients will also depend on how much of their small bowel is remaining and if their colon has been removed or not. Most nutrients are absorbed in the first 100-150cm of the small intestine (except for bile acids and B12, which are absorbed in the terminal ileum). As a result, there is evidence that patients with SBS experience a high prevalence of micronutrient deficiencies.2 Supplementation of micronutrients, often over the recommended dose, is required to manage this. The American Gastroenterology Association published ‘rough’ guidelines for vitamin and mineral supplements for patients with SBS (see Table 1).12 The ESPEN guidelines suggest that clinical signs and symptoms, as well as biochemical measures of trace element deficiency (or

CLINICAL

The management of patients with SBS is complex and needs to be adapted on an individual basis depending on initial diagnosis, length of bowel removed and area of resection. toxicity), be regularly evaluated, and that baseline serum trace element concentrations be measured at the onset of home parenteral nutrition (HPN), followed up at least once per year. It is also noted that trace element doses should be adjusted as needed, and that the route of trace element supplementation should be selected according to the characteristics of the individual patient.5 PHARMACOLOGICAL

Medications are often required for patients with SBS to help manage symptoms, slow transit time and, therefore, improve nutrient absorption.

The use of H2-receptor antagonists, or proton pump inhibitors, may be used to reduce faecal wet weight and sodium excretion. This is especially useful during the first six months after surgery, mainly for patients with a faecal output exceeding 2L/day. They may also be prescribed for long-term management.5 Examples of these medications, which are often used in this patient group, include omeprazole and ranitidine.13 Antimotility medications can be used to increase gut transit time, therefore decreasing intestinal output and reducing nutritional losses.14 The most commonly used medication is loperamide hydrochloride, which may be given in higher than recommended doses and often in conjunction with codeine phosphate.15 For patients with an intact colon, but <100cm of their jejunum remaining, cholestyramine may be prescribed to bind to unabsorbed bile acids which may be contributing to symptoms of

diarrhoea. In addition to this, supplements to replace vitamin/mineral deficiencies may be prescribed.15 PSYCHOLOGICAL

I think it is important to mention the psychological impact SBS may have on patients.

Extensive surgery and often long hospital admissions, followed by potentially long-term enteral or parenteral feeding is a huge life change for anyone and may have psychological impacts.

As well as managing medical/nutritional requirements, healthcare professionals should be aware of this and ensure that they are listening to patientsâ&#x20AC;&#x2122; concerns, ensuring they can signpost to suitable support groups and counselling, as well as wider charities such as the Short Bowel Syndrome Foundation16 and MIND.17 CONCLUSION

The management of patients with SBS is complex and needs to be adapted on an individual basis depending on initial diagnosis, length of bowel removed and area of resection. Particular attention should be made to managing fluid and electrolytes, especially initially after surgery.

Often patients are fed enterally or parenterally, and for those consuming orally, a high calorie diet should be advised. Ongoing review of micronutrient deficiencies is recommended, as well as medications to help manage symptoms.

All these measures highlight the importance of a multidisciplinary team approach in managing patients with SBS â&#x20AC;&#x201C; surgeons, pharmacists, stoma nurses and dietitians all play vital roles. www.NHDmag.com May 2019 - Issue 144

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

NOW CLASSIFIED AS A STAGE

4 PUREED FOOD

* Suitable as a sole source of nutrition from 3–10 years of age and as a supplement from 10 years.

Keyo is a food for special medical purposes and must be used under medical supervision.

NUTRITION MANAGEMENT

KETOGENIC DIETS FOR EPILEPSY: PAST, PRESENT AND FUTURE

This article provides us with a timeline of the ketogenic diet, how it originated and how it has developed over the years, highlighting a 2017 survey that assessed the impact of NICE guidance.

A STEP BACK IN TIME

Reports of starvation associated with a reduction or cessation of seizures in people with epilepsy, date as far back as the Hippocrates era. Centuries later, in the Gospels, Mark (9.29, King James Version) described a boy with seizures, which only ‘prayer and fasting’ could cure.

In the early 1920s, Dr Wilder, from the Mayo Clinic, proposed to mimic the state of starvation and produce ketosis with a high-fat, low-carbohydrate diet.1 This led to the introduction of the socalled ‘classical ketogenic diet (KD)’, typically with a 4:1 ratio of grams of fat to grams of protein and carbohydrate, as a treatment for people with epilepsy.

The initial enthusiasm for the KD was ousted by the discovery of diphenylhydantoin in 1938 and the advent of new easy-to-administer anti-epileptic drugs (AEDs). Although widely used, concerns were quickly raised regarding adverse side effects of these drugs.

In the 1970s, in an attempt to make dietary treatment more palatable, Huttenlocher introduced the MediumChain Triglyceride (MCT) KD.2 Based on the premise that MCTs are more ketogenic per calorie, the MCT KD, which originally derived 60% of its calories from MCT oil, allowed a greater bulk of protein and carbohydrate compared with the predominantly long-chain classical KD. A modified MCT KD was later developed, designed to minimise gastrointestinal side effects, which derived 30% of its calories from MCT oil and 41% from long-chain fats.3

KDs experienced a new lease of life in 1994 following NBC-TV’s Dateline report on Charlie Abrahams, who became seizure-free with KD treatment started at Johns Hopkins Hospital, Baltimore. The Charlie Foundation was then formed by Charlie’s father, the film director Jim Abrahams, helping to further publicise dietary treatment in the public and academic domains with the film First Do No Harm in 1997, and supporting the first multicentre prospective study of the classical KD.4 To this day, the foundation continues to provide information for professionals and families regarding KDs.

Dr Natasha Schoeler, UCL Great Ormond Street Institute of Child Health

Kirsty Martin-McGill, University of Liverpool and University of Chester

THE NOUGHTIES

In the early 2000s, Dr Eric Kossoff from Johns Hopkins Hospital, published on the use of the Atkin’s diet as a treatment for epilepsy5 and, later, on the development of the KD variant, the Modified Atkin’s Diet (MAD).6 The MAD was intended as a more liberal alternative to the classical KD, with fats ‘encouraged’ rather than specifically measured and protein ‘unlimited’.

In 2005, colleagues from Massachusetts General Hospital published on a further ‘liberalised’ dietary regimen, the Low Glycaemic Index Treatment (LGIT), which aimed to minimise the increase of blood glucose following food consumption rather than producing ketones per se.7 The LGIT allowed a greater intake of carbohydrate (around 60% of total energy) compared with other KD types, with only low-glycaemic index foods allowed.

Victoria Whiteley, Royal Manchester Children’s Hospital

REFERENCES Please visit the Subscriber zone at NHDmag.com

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NUTRITION MANAGEMENT In 2008, the first randomised controlled trial (RCT) of classical and MCT KDs to treat drugresistant epilepsy, was undertaken at Great Ormond Street Hospital for Children, London.

38% of children aged two to 16 achieved ≥50% seizure reduction after three months of dietary treatment, compared with 6% controls.8 No difference in effectiveness was found between the classical and MCT KDs.9 This study changed the perceptions of dietary treatment for epilepsy and KDs became more widely available in clinical practice. In 2000, there were 22 centres and 101 patients following KDs in the UK,10 increasing to 28 centres and 152 patients in 2010.11 74% of patients followed the classical KD in 2010 and the remainder followed the MCT KD, despite the aforementioned trend in modified versions of the KD from the USA. PRESENT DAY: THE UK PICTURE AND BEYOND

In 2017, the Ketogenic Dietitians Research Network (KDRN) undertook a survey in the UK and Ireland to assess the impact of the 2012 updated NICE guidance, recommending that children and young people with refractory epilepsy should be referred for consideration of a KD.12 The results demonstrated a 77% increase in services compared with 2000, with patient numbers reaching 754 (KDRN, submitted for publication). Whilst NICE guidance only supports the use of KDs in children, there have also been developments in adult services, with the establishment of seven adult centres.

Despite the rapid increase in services and increased availability of the diet, there is ongoing demand for patients to be considered for dietary treatment: 31 centres reported a waiting list (range 1-49 patients) with 267 patients in total

waiting to start a KD. The main reasons stated for limited service capacity included inadequate funding for dietetic, nursing and medical time. This highlights the need for continued improvements in services nationally and an increasing number of KD dietitians supported by charity funding via The Daisy Garland and Matthew’s Friends.

The 2017 survey showed that classical and MCT KDs are still in use, but use of the MCT KD has significantly declined and a new diet variant, termed ‘modified ketogenic diet’ (MKD) has been introduced.37 MKD in the UK and Ireland is a hybrid KD, adopting principles from other established KD protocols (predominantly high fat and low carbohydrate), but there is little research into its efficacy or cost-effectiveness.

MAD is not in use in the UK and Ireland; LGIT was said to be used in 13 patients, predominantly adults. Additional MCT can be added to each of the dietary protocols as a fine-tuning tool to improve ketosis and seizure reduction. This is reflective of the overall trend in ketogenic practice of allowing more flexibility, but still achieving optimal clinical outcomes.

There is now a growing body of evidence to support the use of KDs, particularly for children with refractory epilepsy,13 with a developing interest in the use of KDs for status epilepticus,14 although further research is required in this area.

There is controlled evidence to show that the benefits of KDs expand beyond seizure control, with improvements in activity, productivity and anxiety in children.15 Our understanding of which epilepsy syndromes and metabolic conditions are likely to respond well to KDs is also improving.

These include glucose transporter type 1 deficiency syndrome, pyruvate dehydrogenase deficiency,

4TH ANNUAL PROGRAMME OF KETOGENIC DIETARY THERAPY LEARNING AND NETWORKING EPILEPSY • DIABETES • NEURO-ONCOLOGY • WORKSHOPS

4TH – 6TH JUNE 2019 www.mfclinics.com/keto-college 30

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NUTRITION MANAGEMENT

There is controlled evidence to show that KDs can positively impact cognition in people with epilepsy. epilepsy with myoclonic-atonic seizures, infantile spasms, tuberous sclerosis complex and Dravet syndrome.16 The use of KDs in adults is growing in popularity following the publication of two recent trials,17,18 both of which illustrated a ‘moderate’ improvement in seizure control, although limited by small sample sizes. An adequately-powered RCT would be of benefit in this population to investigate both clinical and cost effectiveness.

With the increase in use of KDs and the growing body of evidence supporting their efficacy in epilepsy, national and international guidelines have, and continue to be, produced.

This includes an updated international consensus statement on use of KDs for children with epilepsy, with advice ranging from who is eligible for consideration of a KD, prevention and treatment of adverse effects and how to discontinue dietary treatment.16 Specific guidance has also been published on use of KDs in infants19 and work is underway on guidelines for the use of KDs in parenteral nutrition and within an intensive care setting for status epilepticus.

As the indications for and number of patients on KD has increased, so has the number of prescribable products available to support patients, families and professionals. Products now include a specific formula for infants (Nutricia’s KetoCal 3:1) and for adults (Nutricia’s KetoCal 2.5:1 LQ), cereal bars and ready meals (Ketoclassic range by Ketocare) and a chocolate pudding (Keyo by Vitaflo International Ltd).

There has also been development of online support tools including EKM, MyKetogenicDiet (Vitaflo International Ltd) and Myketoplanner (Nutricia Metabolics), aiming to improve compliance and accessibility to KDs.

FORWARD FACING

Use, and the potential uses of KDs is expanding, both for epilepsy and beyond. Following a plethora of case series over the past few decades, a nationwide RCT is currently underway to determine the efficacy of the classical KD in infants.20 Evidence, although preliminary, is also mounting for use of KDs in cancer,21,22 neurodegenerative diseases,23 Alzheimer’s disease,24 autism spectrum disorder25 and migraines,26,27 to name but a few.

There is continued interest in the potential mechanisms of action of KDs, with the ultimate aim of making dietary treatment easier and more accessible. There is particular focus on medium chain fatty acids,28 including decanoic acid29,30 and triheptanoin,31 and the role of the gut microbiota32 at present.

In addition, enhancing understanding of predictors of response to KDs continues to be at the forefront of research interests, with particular regard to genetics,33 epilepsy syndromes and seizures types34,35 and biochemical parameters.36 The UK and Ireland’s contribution to KD research is ever-mounting with the creation of national groups, such as KDRN, promoting communication, idea and resource-sharing and supporting dietitian-led research and international collaborations.

CONCLUSION

KDs are more accessible than ever. However, in this rapidly developing field of dietetics, further research is required. Networks, such as KDRN, are essential in fostering research collaborations, clinical support systems and promoting the excellent work of ketogenic dietitians. www.NHDmag.com May 2019 - Issue 144

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PAEDIATRIC

PROBIOTICS AND PAEDIATRIC GUT HEALTH

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

Gut health is a big contemporary talking point. We know that gut microflora is largely influenced by our diets and that a human’s entire life diet can be determined by analysing gut microbiota. The average person is becoming more aware of the fact that we host helpful bacteria, which populates our digestive systems and can influence our physical and mental wellness.

A human adult carries around 0.2kg of bacteria1 with the gastrointestinal system carrying a cocktail of bacteria, including Lactobacillus, Streptococcus, Bacteroides and Candida. The ultrahealth conscious amongst us now brew their own kefir and eat a myriad of bacteria-promoting foods, and faecal transplants have been popularised in the media. The impact of the overall microbiome on health is thought to be so vast that, similarly to the Human Genome Project, the Human Microbiome Project2 has been pioneered in order to understand the microbiome’s role in conjunction with the rest of the human body, and the gut microbiota is merely one component of this complex system.

In the last five years or so, increasing evidence is suggesting that not only can probiotics help maintain a healthy gut and immune function in children, but can also contribute to reducing the risk and prevalence of disease.

FUNCTIONAL FOODS – PROBIOTICS AND PREBIOTICS

Some foods confer additional health benefits beyond the basic nutrition provided by the food itself. Some foods may contain live cultures of beneficial bacteria (probiotics), such as Lactobacilli and Bifidobacteria.

The WHO define a probiotic as a ‘live organism, which provides a benefit to the host when provided in adequate quantities’.3 32

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Other foods are indigestible to humans, but are selectively digestible by mutualistic microflora in the large intestine, the by-products of which in turn promote a healthy gut – these are prebiotics. Prebiotics are most commonly non-digestible oligosaccharides, such as fructo-oligosaccharides (FOS) and galacto-oligosaccharides (GOS). Both probiotic and prebiotic-containing foods, then, are examples of functional foods. Mutualistic gut microflora not only produce useful compounds, but have a protective effect against nefarious bacteria, such as sulphate-reducing bacteria and Pseudomonas aeruginosa.

AEROBIC VS ANAEROBIC DIGESTION

Unlike in aerobic human systems, where carbohydrates are converted into energy, carbon dioxide and water, the anaerobic processes within gut bacteria convert carbohydrates into energy, organic acids and hydrogen. Varying short-chain fatty acid (SCFA) patterns are produced by different gut bacteria: bacteriodetes produce mainly acetate and propionate, whilst firmicutes produce butyrate, which is the SCFA with the biggest role in human health.

Propionate has a role in metabolism and satiety and acetate is the most abundant.

SCFAs can be detected in biological samples.

It has been proposed that SCFAs may have wider metabolic effects, specifically in regards to appetite and obesity. This suggestion comes in

PAEDIATRIC

Now evidence is emerging that suggests probiotics can tangibly aid in the direct treatment or prevention of some diseases in infants and children.

response to the observation that a high-fibre diet provides protection against obesity. Moreover, a recent study supplementing overweight adults with an inulin-propionate ester for six months showed weight gain prevention.4 In the absence of carbohydrates, bacteria can still ferment alternative molecules, ie, protein and fats. Products of protein fermentation include ammonia, tryptophan metabolites and phenolic compounds, which are potential carcinogens; protein fermentation has been implicated in colorectal cancer and ulcerative colitis.5,6 Another positive role of gut microbiota is in the synthesis of a handful of water-soluble (B group vitamins, vitamin C) and fat-soluble vitamins (vitamin K); the vitamins produced depend on the specific bacteria genera. In turn, some of these vitamin products may be available for human nutrition if colonic absorption is possible, as the colon does have specific carriers for vitamin absorption.

Bile salts aid in the absorption of fat-soluble vitamins, as well as the absorption of fat and cholesterol, by acting as a detergent. There are over 30 bile salts and the diversity of these is driven by gut microflora.

Non-pathogenic commensal gut bacteria interact with the host-associated immune system through either direct interaction and/ or chemical mediators, thereby improving host immune function. Constant and impactful

antigenic stimulation from invasive pathogens gives the host immune system strong protective immunity.7,8 DIET AND GUT MICROBIOTA

The numbers and types of bacteria are determined by diet. A typically â&#x20AC;&#x2DC;Westernâ&#x20AC;&#x2122; diet, comprised of animal protein and high saturated fat, lends itself to a gut microbiota populated substantially by Bacteriodes species, whereas the gut microbiota of an individual following a vegan or vegetarian diet is more likely populated by Provotella species.9 Probiotics are marketed as beneficial to childrenâ&#x20AC;&#x2122;s immune systems and, so, are administered in average diets in the form of yoghurts and yoghurt drinks, in a bid to diversify the gut microflora and take advantage of the protective effects probiotics can impart.

Now evidence is emerging that suggests probiotics can tangibly aid in the direct treatment or prevention of some diseases in infants and children.10 PROBIOTICS AND INFECTION IN HUMANS

Administration of probiotics in children has been shown to hasten recovery from rotavirus and non-bloody diarrhoea and decrease the incidence and severity of diarrhoea in day care centres, as well as decrease the duration of antibiotic-induced diarrhoea. www.NHDmag.com May 2019 - Issue 144

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PAEDIATRIC In as early as 1994, in a randomised trial with five to 24-month-old hospitalised infants with a variety of conditions, infants were assigned a formula containing Bifidobacterium bifidis and Streptococcus thermophiles. Over 80 days, 31% of the infants with the control formula had diarrhoeal disease episodes, compared with 6.9% of infants with probiotic-containing formula.11 In an even earlier study conducted in 1991, four to 41-month-old infants hospitalised with acute diarrhoea had a reduced diarrhoea and rotavirus diarrhoea duration when administered Lactobacillus casei.12 A Cochrane meta-analysis of 25 studies looking at probiotics and antibioticassociated diarrhoea uncovered a pattern of an overall 0.43 reduction in risk ratio.13 Furthermore, probiotics have been seen to have a positive effect in preventing acute upper respiratory tract infections (URTI): the results of a systematic review show that probiotics were more effective than placebos in reducing the number of participants experiencing at least one episode of acute URTI, three or more episodes of acute URTI, as well as reducing antibiotic use.14 In a small number of intestinal diseases, such as Crohn’s disease, probiotics have not been seen to have any tangible health benefits, though more research is needed to confirm whether probiotics are completely ineffective, or might still have some effect on Crohn’s prognosis.15 PROBIOTICS AND NEONATES

The colonisation of gut microbiota proceeds directly after birth. Neonates have an immature immune system, though immunoglobulins can cross from the mother to the foetus via the placenta. Breast milk factors, such as immunoglobulins, carbohydrates, cytokines and leukocytes, can provide passive immunity and promote appropriate maturation of the newborn’s gastrointestinal system. The numbers and types of bacteria are influenced by disease – one study on Estonian and Swedish children over the first year of life, showed that those who were allergic to one or more agents had lower levels of Bifidobacteria. Similarly, pregnant women with family histories of atopy were randomly assigned placebos or L. casei in capsules two to four weeks prior to delivery; this treatment was continued postnatally. At two years and in a 34

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follow-up at four years of age, the infants in the treatment group had a lower incidence of atopic eczema than those in the control group.16,17 PAEDIATRIC DISEASE

Antibiotic use during pregnancy and early pregnancy often correlates with increased body size and risk of being overweight in childhood and beyond. The same risk is in place for babies born prematurely or by Caesarean section.

Obesity has been linked to changes in gut microbiota at the phylum level. Unsurprisingly then, longer duration of breastfeeding is protective of obesity.18 Repeatedly, decreased gut microbial diversity in infants is seen to contribute to chronic IBD, diarrhoea and necrotising enterocolitis, all diseases linked to dysbiosis of commensal gut microflora and the gastrointestinal tract.19,20 GUT-IMMUNE-BRAIN AXIS

There is increasing evidence to suggest strong links between the gut microbiota and the brain.

Some studies have demonstrated a link between individuals suffering from stress, anxiety and depression and their gut microbiota.21,22 SUMMARY

There is unequivocal evidence that probiotics are effective in managing and preventing illnesses of and relating to mechanisms of the gut, such as diarrhoea, obesity, acute respiratory infection, chronic IBD and enterocolitis. Weaker evidence suggests some link between probiotic use and Crohn’s disease and atopic disease, amongst others. Additionally, there is now plentiful evidence to suggest that diversity of the diet contributes to a thriving gut microflora, which in turn provides immune defence and protective action against pathogenic bacteria. Neonates are greatly affected by their mother’s gut microflora and birth complications, such as preterm birth and C-sections, have been associated with altered neonate microbiota, which, in turn, increases the risk of a host of gut-mediated diseases. There is certainly scope for more research in this area – the Human Microbiome Project2 will be instrumental in demonstrating the diversity of gut microbiota and how this complex microflora varies in humans.

HEALTH & WELLBEING

INTUITIVE EATING This article will outline the history of intuitive eating (IE), its development and the evidence base, with an overview of the potential for application of IE in clinical nutrition and dietetics.

IE has become increasingly popular in recent years, forming a bit of a buzz word in the health and wellbeing sector. With research having shown links between rigid dietary control and lower levels of psychological wellbeing and disordered eating,1 IE was developed in order to address problematic relationships with food, physical activity and body image that may be brought on, or exacerbated by, dieting.

In 1995, dietitians Evelyn Tribole and Elyse Resch outlined IE as an evidencebased approach to health (although there were some similar earlier iterations), focusing on improving health behaviours by paying more attention to signals of hunger and fullness from your own body rather than external indicators. IE includes approaches to help with developing more positive body image and does not focus on weight as a primary outcome measure or indicator of health.

There has been some confusion around the application of the principles of IE in general and also when applied to clinical nutrition. IE is defined by Tracy Tylka, a prominent IE researcher, as, ‘a flexible style of eating in which you largely follow your internal sensations of hunger and satiety to gauge when to eat, what to eat, and when to stop eating.’2 This contrasts with the traditional rules of dieting for weight loss, which may

rely on external cues, like meal plan timing and macronutrient adjustment to guide eating patterns and foods.

There are no set rules to follow so it’s not possible to do it ‘wrong’. Instead, there are 10 principles which outline the theory and provide tools and activities for developing this attunement (see Table 1).

The principles are designed to provide some insight into any obstacles to this interoceptive awareness, such as the development of long-held beliefs about food (eg, having to eat everything on our plates), any moral attribution to foods (eg, foods being inherently ‘good’ or ‘bad’) and the importance of finding enjoyment and satisfaction in food and movement where possible. There is also an emphasis on developing a ‘toolkit’ for handling our emotions without just using food.

The importance of self-care in overall health is highlighted, as poor sleep and general lack of self-care will likely affect our eating and activity patterns.

Jessica English RD Freelance Dietitian, founder at Level Up Nutrition Jess runs Level Up Nutrition, working with individuals on a one-to-one basis in Brighton and online UK-wide. Jess has a special interest in health communications and global public health nutrition.

REFERENCES Please visit the Subscriber zone at NHDmag.com

DEVELOPMENT OF TOOLS FOR IE RESEARCH

Following the development of the IE principles, a 21-item scale was created and refined by Tylka in 2006, in order to assess levels of IE in research and within the population: the IES.3

Table 1: The 10 principles of intuitive eating 1 Reject the diet mentality

6 Discover the satisfaction factor

2 Honour your hunger

7 Honour your feelings without using food

3 Make peace with food

8 Respect your body

4 Challenge the food police

9 Exercise – feel the difference

5 Respect your fullness

10 Honour your health – gentle nutrition www.NHDmag.com May 2019 - Issue 144

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YOUR ESSENTIAL RESOURCE

HEALTH & WELLBEING Research by Tylka published in 2013 is the largest study to date on IE, (n= 2600), updating and validating the original IE assessment scale, which now has 23 items (IE-2). An additional category was added to address body-food choice congruence in order to assess aspects of ‘gentle nutrition’.4 This validated and refined scale has been used in much of the IE research to date as a tool to assess how intuitively participants eat. Modified versions have been developed in order to assess effectiveness in participants from different cultural backgrounds.5 NUTRITION, HEALTH AND IE

There has been some debate over the IE approach to nutrition; with many presenting it as an opportunity to ‘eat what you want, whenever you want – no matter the consequences’. However, with IE having been developed by dietitians, nutrition is understandably an important part of it, with Tribole and Resch advocating an approach they refer to as ‘gentle nutrition’.

This gentle approach involves all of the standard (non-weight focused) nutrition guidelines, presented as an approach more akin to self-care, as opposed to focusing on food restriction. Research has shown that focusing on improving health behaviours independent of weight can have positive health outcomes with or without weight loss.6 Higher levels of IE have also been associated with improved outcome measures for health, regardless of weight changes.7 All foods (unless medically advised otherwise, or excluded for ethical, taste or moral reasons) are included and there is a focus on the healthpromoting properties of the more nutritionally dense foods, with less nutritionally dense foods enjoyed mindfully where possible, but not completely excluded. Variety and moderation are encouraged – again echoing standard nutrition guidelines.

IE IN CLINICAL NUTRITION

There is some debate over where IE fits with clinical nutrition, as prescriptive diet plans for many medical conditions wouldn’t necessarily align with the intuitive aspects.

Using clinical judgement, it is understandably not appropriate to attempt such an approach in a 10 or 15 minute slot in an acute setting. A clinical setting and acute illness will likely also prevent a patient from being able to eat intuitively.

IE is not intended to replace any part of clinical nutrition and instead may be used as an adjunct approach alongside traditional medical models. It is likely more suited to an outpatient or community setting, where more time can be spent working on some of the principles to address longer-term health goals.

Other aspects of IE could be applied, with support, for those managing chronic conditions in the community, such as rejecting the dieting mentality in favour of balance and moderation and attunement to hunger/fullness signals.

IE IN WEIGHT MANAGEMENT

It is generally accepted that traditional methods of dietary restriction for weight management, although potentially effective in the short term, are ineffective for the majority of dieters over the longer term. It appears that dieting specifically to reduce weight may even be associated with weight gain in the longer term.8 Tribole and Resch advise against using IE as an approach for weight loss, as the focus on weight and appearance may interfere with attunement and overrides any basis for intuition.

Though not intended for the purpose of weight loss, there have been many studies into the effectiveness of IE as a tool for weight management. Higher levels of IE have been associated with lower BMI3,9,10 and certain aspects of IE, such as more attuned and mindful eating (though mindful and intuitive eating are different, there are many mindful aspects to IE) and the ‘hunger scale’, have been used elsewhere in weight management programmes including NHS programmes.11,12 Research is ongoing into whether this would mean that IE would be an effective weight management tool.

It is difficult to ascertain causality from the available research at this time in order to establish whether those who eat more intuitively are more likely to have a lower BMI, or whether IE can be used as a tool for weight management.

IE IN DIABETES

There have been a number of studies into IE and diabetes, including research from 2016 which showed a link between IE and improved glycaemic control in teenagers with Type 1 diabetes (T1DM)13 . There was a strong inverse www.NHDmag.com May 2019 - Issue 144

37

HEALTH & WELLBEING statistical association between eating for physical rather than emotional reasons and HBa1c.

In general, those with T1DM had a lower overall IE score than a control group. This may be expected, as those with T1DM may have been required to override their natural hunger/fullness in order to manage their blood glucose levels.

The researchers highlight the potential to use this research to screen for emotional eating behaviours in those with T1DM in order to improve HBa1c outcomes.

In Type 2 diabetes (T2DM), IE has been linked with enhanced glycaemic control in AfricanAmerican women with T2DM.14 This research also highlighted some confusion around dietary interventions in T2DM and the effects of stigma in healthcare.

EATING DISORDERS

As chronic dieting and disordered eating can affect the ability to acknowledge innate hunger and fullness cues, there has been much interest in the application of IE in the treatment of eating disorders (ED). IE has been shown to be linked for positive outcomes for ED patients, including anorexia nervosa and bulimia nervosa.15 A mixed-sex study has also shown that although IE is again inversely associated with BMI in both reported sexes, it is also inversely associated with binge eating and other disordered eating behaviours: â&#x20AC;&#x2DC;Males and females who reported trusting their body to tell them how much to eat had lower odds of utilising disordered eating behaviours compared with those who did not have this trust.â&#x20AC;&#x2122;16 There is also some promising evidence that IE interventions may be useful in preventing the development of disordered eating, though, again, it may be difficult to apply these results to a wider population.

OTHER OUTCOMES FROM IE

Those who participate in IE studies report better psychological wellbeing, self-esteem, body appreciation and, in general, attrition rates are lower than with traditional dietary interventions.17,18 Women who show higher levels of IE have also been shown to be less likely to display disordered eating patterns and have better body image,19 although the majority of these studies have been cross-sectional and carried out at universities in 38

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the United States. Further prospective studies in a wider population are needed.

LIMITATIONS

The efficacy of IE public health interventions is unclear, largely due to the difficulties of applying and assessing the principles in public health settings. There is also only limited application of the principles in those with low incomes and reduced food choices, as food scarcity and the need to eat for survival overrides the likelihood or need to eat intuitively.

This does present limitations to the application of IE when compared with other interventions, though some aspects of IE may potentially be applied in some circumstances, ie, addressing food rules and body acceptance.

Guidance when following the principles of IE is recommended for those with any medical condition, or with a history of disordered eating.

SUMMARY

There is mounting evidence that being a more intuitive eater is associated with a host of holistic benefits, including improved psychological outcomes, reductions in binge eating and disordered eating, self-compassion and body acceptance.

There is some evidence to support the use of IE in improving HbA1c in those with diabetes (T1DM and T2DM) - though further research is needed.

Although IE is not intended to be a primary outcome measure for an ED intervention, it may be a useful tool in developing long-term behaviour changes around food and activity that could attenuate further weight gain and bring health benefits independent of any weight changes.

Further research is needed into the effectiveness of IE as an intervention or assessment tool in a number of chronic conditions where eating is limited and rates of disordered eating may be high, such as with coeliac disease and inflammatory bowel disease.

Overall, IE appears not to be harmful for those who undertake it, though supervision and guidance is advised for those with any medical condition, or for those with a history of or potential susceptibility to disordered eating. The approach doesnâ&#x20AC;&#x2122;t seek to replace traditional clinical thinking, but, instead, focuses on improving potentially disordered relationships with food.

IN ASSOCIATION WITH THE NSPKU

PHENYLALANINE NEUROTOXICITY AND THE CHALLENGE OF ‘DIET FOR LIFE’* IN PKU Lifelong phenylalanine (Phe) restriction, with intake of protein substitutes, is essential for the prognosis of PKU, but is burdensome, considerably demanding and often difficult to follow. This article looks at the mechanisms for brain damage in PKU and outlines some of the evidence supporting ‘Diet for Life’.

Phenylketonuria (PKU) is a rare autosomal disorder of phenylalanine (Phe) metabolism. It was first discovered in 1934 and occurs due to inherited mutations in the gene encoding Phe hydroxylase. Lifelong Phe restriction and intake of protein substitutes are both essential, yet demanding and often difficult to follow. Consequently, many patients stop following the PKU diet and may also become disengaged from metabolic review. Furthermore, non-metabolic dietitians may discover patients with PKU who have been ‘lost to follow-up’ and have been referred into other dietetic caseloads.

Irrespective of their discovery, it is important that these patients are offered metabolic specialist input to facilitate a return to diet, or, at the very least, provided with robust scientific evidence so they can make informed choices about being off diet and the chance to be under detailed nutritional scrutiny by metabolic dietitians and other members of the multidisciplinary metabolic team.

WHAT IS THE PATHOPHYSIOLOGY AND MANAGEMENT OF PKU?

PKU is characterised by disrupted catabolism of Phe into tyrosine and its metabolites. The metabolites of tyrosine act as precursors of several neurotransmitters, catecholamines and hormones, including dopamine, norepinephrine, epinephrine, thyroxine and melanin. Without appropriate management, Phe accumulates in the blood and becomes neurotoxic.

For the unmanaged or poorly managed individual, chronically elevated Phe manifests in a spectrum of progressive and irreversible neuroanatomical and neurophysiological disturbances. With the introduction of newborn screening, PKU became the first metabolic disorder identifiable in the absence of clinical symptoms. Early identification (via newborn screening) and immediate (before 10-14 days of age) dietary intervention is essential for the prognosis of this disorder, whereby patients can achieve almost normal clinical outcome in comparison to their non-PKU counterparts if blood Phe concentrations are maintained at a necessary level.

WHAT IS THE CURRENT ADVICE FOR PATIENTS?

PKU management is by way of a lowprotein diet and intake of protein substitutes virtually devoid of Phe. The PKU diet is well established, safe and effective and, consequently, remains the cornerstone of PKU management and has been since its conception in 1953.

The duration and stringency of Phe restriction necessary to avert the metabolic consequences of PKU, has been the centre of controversy for decades.

Historically, lifelong Phe restriction was generally unsupported. Many practitioners assumed that the diet could be discontinued from age six with no adverse effect.1,2 This practice was fuelled by the belief that elevated Phe is only neurotoxic during periods of growth, development and maximal myelinisation (the development of a protective

IMD WATCH

Suzanne Ford RD Dietetic Team Leader, Bristol Southmead Hospital; Society Dietitian (Adults), The National Society for Phenylketonuria

Dr Ben Green PhD Medical Affairs Research Advisor, Nutricia Advanced Medical Nutrition

REFERENCES Please visit the Subscriber zone at NHDmag.com

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IMD WATCH

"Mental health problems occurred after stopping the diet."** cover around a nerve fibre called myelin), as is experienced during childhood. Several early studies also failed to demonstrate adverse effects on neurocognitive and psychosocial development with early diet discontinuation.3-5 These studies, however, consisted of small sample sizes and varied considerably in methodological validity with little practical and/or clinical application.

Although brain development happens mostly in the first years of life, it has long been known that development of the prefrontal cortex and myelinisation continues through adolescence and is not complete until adulthood. It is suggested that the toxicity of Phe is, therefore, present well into adult life and this was recently strengthened with publication of The European Guidelines for Diagnosis and Management of PKU,6 which were based on a significant amount of research.

Adult patients who stop the PKU diet appear to experience poor executive functioning, information processing (reaction times, attention) and mood (increased inhibition, anxiety, depression and low self-esteem) compared with adults who have continued Phe restriction throughout life and also metabolically healthy controls.7-11 On some occasions, reports of neurological problems have also been noted, even with good metabolic control and continued Phe restriction.12-14 Importantly, research shows that returning to a Phe-restricted diet can reverse these complications.15,16 ‘Diet for life’ is now encouraged, but because it can be difficult to follow, many patients decide to come off diet.

WHAT ARE THE PROPOSED MECHANISMS FOR BRAIN DAMAGE IN PKU?

The pathogenesis of Phe toxicity is complex and far from being fully understood. Although elevated Phe is undoubtedly detrimental to the brain, the underlying causes for this effect remain 40

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hypothetical. Two likely mechanisms responsible for neurological decline have been identified and include white matter pathology (hypomyelination) and neurotransmitter abnormalities that act on prefrontal cortex function.

WHITE MATTER PATHOLOGY AND HYPOMYELINATION

In the brain, white matter is found in the deeper tissues (subcortical). It contains nerve fibres (axons), which are extensions of nerve cells (neurons). Many of these nerve fibres are surrounded by a covering called myelin. Myelin gives the white matter its colour and acts to uphold the speed and transmission of electrical impulses.17 Increased concentrations and damage to the structure of white matter is highly prevalent in PKU, with an estimated 90% of patients experiencing abnormalities.18 Raised Phe appears to principally affect subcortical white matter.

The progression and severity of white matter abnormalities appears to be influenced by: • age (with increased severity from 20 years onwards); • compliance to Phe restriction; and • long-term exposure to raised Phe levels.19 It is thought that long-term exposure to raised Phe stops the formation of myelin and the increased white matter reflects this (hypomyelination).18 As myelin plays a role in the transmission of electrical impulses, disturbances in executive functioning and the effectiveness of information processing supports the hypothesis that raised Phe levels influence myelinisation as a result of stopping the PKU diet. Interestingly, research shows that this pathology can be reversed when the PKU diet is restarted with strict compliance.18 The duration of strict metabolic control needed to significantly reduce white matter abnormalities is not known, but reversal is not instant. It is clear, however, that the reversal of white matter is associated with the lowering of blood Phe concentration. According to imaging studies,20 two months of strict Phe restriction may be needed as a minimum.

NEUROTRANSMITTER ABNORMALITIES

Phe neurotoxicity is also associated with prefrontal cortex dysfunction as a consequence of neurotransmitter abnormalities. Due to disrupted

IMD WATCH Phe catabolism and a higher uptake of Phe into the brain,21 deficiencies in tyrosine and its metabolites occur with low levels reaching the brain,22 which is detrimental for neurotransmitter production.

Phe, a large neutral amino acid (LNAA), is transported into the brain by the L-amino acid transporter 1 (LAT-1).21 This transporter also selectively transports other LNAA, including valine, isoleucine, methionine, threonine, tryptophan, tyrosine and histidine.22 The binding of LNAA to the LAT-1 transporter is a competitive process.23 This system has the highest attraction for Phe, therefore, high concentrations of Phe in the blood lead to an increased uptake of Phe into the brain and a concomitant decrease in the uptake of tyrosine and other LNAA.21 By influence of this activity, elevated brain Phe concentrations negatively impact the synthesis of catecholamines (dopamine, norepinephrine and epinephrine) and serotonin in the brain.

This is due to the altered metabolism of tyrosine and tryptophan, which may subsequently affect the proper functioning of the brain, especially in the prefrontal cortex. In general, the prefrontal cortex exerts a role in planning complex cognitive behaviour, including decision making, executive functions and emotional stability. The abnormalities in neurotransmitter functions subsequently disturb cerebral protein synthesis and impact the aforesaid functions, even in patients who were managed early in life. Again, returning to a Phe-restricted diet results in improvements in executive functioning, decision making and emotional stability.15,16 Furthermore, there is evidence that the intake of protein substitutes containing high levels of large neutral amino acids reduces the uptake of Phe into the brain23 and further improves elements of executive functioning.24 IS ‘DIET FOR LIFE’ HAPPENING IN THE UK?

Unfortunately, poor compliance with lifelong Phe restriction in PKU is widespread.26-28 This is especially true in older adolescents and adult populations.29 A recent survey highlighted that 43% of adult PKU patients in the UK admitted to

"The psychological effects of high levels of Phe are entirely underestimated: minimal concentration and brain fog."** not following a low-protein, Phe-restricted diet.30 If the PKU diet has been stopped (either due to medical advice, or in the absence of any positive outcome, or support to continue on the diet), then returning to the diet is advisable. The PKU diet, however, is complex and highly restrictive and does require planning skills, motivation and discipline. Returning to the diet may, therefore, be especially difficult for patients who are/have been off diet due to compromised executive functioning.

Collectively, there are many difficulties associated with re-establishing Phe restriction; thus, it seems prudent that efforts to maintain lifelong Phe restriction are needed. The patients’ multidisciplinary management team may represent the first-line defence for this and, with the evidence discussed above, the team can, and should, act as advocates to encourage a ‘Diet-for-Life’ philosophy.

WHAT DOES A RETURN TO DIET MEAN FOR DIETITIANS AND THEIR PATIENTS?

Alongside improvements in white matter pathology and neurotransmitter metabolism, patients who return to the PKU diet also show marked improvements in quality of life.31 Strategies aimed at improving dietary compliance are, however, relatively understudied in PKU. No one method will be universally effective and an individualised approach to reinstating dietary compliance may be essential. Research is, therefore, needed to help build effective strategies that deliver metabolic, nutritional and cognitive benefits with the overarching aim of achieving lifelong dietary compliance over time.

* This information is intended for healthcare professionals only ** Quotations are taken and reproduced with permission from a recent UK survey30 capturing the issues of living with PKU in children and adults. In particular, the quotations used throughout this article are in response to the free text question, “Is there anything else about your experience of having PKU (or the person with PKU under your care) which you would like to share?” www.NHDmag.com May 2019 - Issue 144

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COMMUNITY

A FOOD-FIRST APPROACH TO EATING AND DRINKING WELL

Gill Hooper Freelance Registered Nutritionist Gill works in training and education around nutrition and hydration to provide quality dementia and frailty care. She is currently working with Bournemouth University looking at the impact of improving nutritional care for people with dementia.

REFERENCES Please visit the Subscriber zone at NHDmag.com

With an ageing population and increasing numbers of people at risk of undernutrition, it is important to identify those at risk and encourage food and drink intake through a food-first approach.

It is estimated that over three million people in the UK are affected by malnutrition, or ‘undernutrition’ and of those, approximately 1.3 million are over the age of 65. Most of these people are living in their own homes in the community. According to BAPEN nutrition screening week surveys (200711), 30-42% of people admitted to care homes are at risk of malnutrition.1 A report, The cost of malnutrition in England and potential cost savings from nutritional interventions, published by the National Institute for Health Research, Southampton Biomedical Research Centre (NIHR Southampton BRC) and BAPEN, says that the estimated cost of malnutrition in both adults and children in England in 2011-12 was £19.6 billion.2 With an ageing population and rising costs of health and social care, this figure is likely to increase and is an issue which needs to be addressed.

WHY IS THERE A PROBLEM?

There are a number of factors which increase the risk of malnutrition, from social factors such as living in isolation and poverty, having little knowledge of nutrition, or inability to cook, to medical factors including mental health conditions, cancer, dementia and dysphagia. Physical factors, such as poor dental care and limited mobility, may also increase the risk of malnutrition.

An older person living alone may be socially isolated, unable to get out to the shops to buy food because of reduced 42

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mobility, have difficulty eating due to a loss of ability, or may have a loss of appetite. For someone living with dementia, eating and drinking can become increasingly difficult as the dementia progresses; there may be confusion recognising food, or remembering how to eat, difficulties with chewing and swallowing, or a change in food preferences.

There is a widely held belief that weight loss is a normal part of ageing, but this is a myth. Unexplained, or unintentional weight loss, is a serious issue and can lead to the risk of malnutrition. This in turn can result in a greater susceptibility to illness and disease, a delay in recovery, reduced muscle strength and the risk of falls. At least 25% of people admitted to hospital are at risk of malnutrition,1 resulting in further deterioration and poor clinical outcomes. This vicious spiral is demonstrated by the ‘Malnutrition Carousel’ (see Figure 1).

As we have seen, over one million people in the UK over the age of 65 and living in the community are undernourished. How can we reduce malnutrition and encourage food and drink intake for those at risk?

Nutritional support should always be appropriate to individual needs, but generally, a ‘food-first’ approach is best.

For people who are undernourished, underweight or at risk of malnutrition, it is important that food and drinks contain

COMMUNITY Figure 1: The ‘Malnutrition Carousel’ (BAPEN)3

as much energy and protein as possible. Advice should be given on how to adapt meals and snacks by adding small amounts of high energy and protein foods to increase the energy and nutrient content without increasing portion sizes. Much of this advice goes against traditional ‘healthy eating’ messages. However, a food-first approach is the best way to help prevent weight loss.

But, how can we identify those at risk and begin conversations about good nutrition and hydration and avoid the vicious spiral described above?

THE PAPERWEIGHT ARMBAND

In 2013, Salford, in Greater Manchester was chosen as a pilot area to be part of the Malnutrition Prevention Programme4 for 12 months. The programme encouraged a whole community approach to tackle malnutrition, including local NHS Trusts, GPs, hospitals, care homes and community groups; its aim being to significantly reduce the number of people aged 65 and over who are malnourished.4 Five key principles to providing good nutrition and hydration care were identified:4 1 Raise awareness of malnutrition.

2 Work together.

3 Identify older people who are malnourished or at risk.

4 Provide support, care and treatment and monitor progress.

5 Monitor and evaluate your activities.

In Salford, a nutrition committee was established and along with Age UK Salford, the PaperWeight Armband was developed.5 The armband is a non-intrusive intervention that can be implemented quickly and easily by healthcare providers and the voluntary sector. It is a simple strip of paper used to measure the upper arm; if it can slide up and down easily, there is a high risk of malnutrition.

The Armband was piloted by Age UK Salford with support workers using it on their home visits. If someone was identified at risk, further information, advice and support was given on simple dietary changes that could be made to increase energy intake.

The Armband was launched at Food Matters Live in 2015 and is now promoted throughout Greater Manchester by the Greater Manchester Nutrition and Hydration Programme, which aims to make sure older people are eating and drinking well enough to keep healthy and remain independent. They are doing this by raising awareness of undernutrition in the community through various activities, providing training and using the paperweight armband to identify those who are risk of undernutrition. Activities have included a ‘Lunch and Learn’ group where over-65s come together for a meal with children from a local nursery and all learn about eating and drinking well.

A 76-year-old woman, whose malnutrition was identified through the Armband, said: “I was www.NHDmag.com May 2019 - Issue 144

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COMMUNITY Table 1: Suggestions for high energy snacks and drinks10 Crisps Sausage rolls Toasted crumpets and cheese Dried fruit Small chocolate bar Scones with jam and cream Chocolate digestives Fruit and custard Ice-cream Mousse Hot chocolate and marshmallows Fruit juice Regular fizzy drinks

Savoury Handful of nuts Pork pie Creamy soup Sweet Banana Malt loaf Jelly sweets Croissant/pain au chocolate Dessert Trifle Full fat yoghurt Rice pudding Drinks Milky coffee Fruit smoothies

Hummus and bread sticks Cheese and biscuits

Shortbread Cakes Flapjack Muffins Cream meringues Milk jelly Tinned fruit in syrup Hot malted milk Milk shake

It is important to remember that some of the sugary snacks and drinks listed may not be suitable for people with diabetes.

Table 2: How to increase energy content through food fortification10 Food to be fortified

Amount

Energy before (Kcal)

Whole milk

568ml

375

4 tablespoons dried skimmed milk powder

583

Custard

125ml

148

Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream

349

Milk-based soup

125ml

80

Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream

280

Porridge with whole milk

200g

226

Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream

426

1 scoop

70

Add 1 tablespoon of butter & 1 tablespoon double cream

183

Mashed potato Vegetables

Add these ingredients to increase energy content (Kcal)

Energy after addition (Kcal)

2tbsp

15

Add 1 teaspoon of butter

52

Baked beans

80g

67

Add 1 teaspoon butter and 20g grated cheese

188

Scrambled egg with whole milk

120g

308

Add 1 teaspoon of butter, 2 teaspoons dried skimmed milk powder and 45g cream cheese

603

Rice pudding

125ml

106

Add 1 tablespoon of dried skimmed milk powder & 2 tablespoons double cream and 2 teaspoons of jam

332

admitted to hospital because I was dehydrated and was there for four days. After this, I was not able to go out and buy my own food and I lost a lot of weight. I was down to 7 stone.” After using the Paperweight Armband this lady was referred to the Lunch and Learn group and subsequently gained 2.5 stone. She said, “It gets me out and got me talking to people because I never talked before, I was just on my own.”6 44

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Most importantly, the programme promotes a food-first approach and a number of useful resources have been produced, including diet sheets7 and a booklet entitled, Are you eating enough?.8 In November 2018, Greater Manchester Health and Social Care Partnership reported that, “In the three years since the ‘PaperWeight Armband was introduced in Salford, it has resulted in a 50% increase in cases of malnutrition

COMMUNITY Table 3: Suitable ingredients for fortifying food10 Add this food

Quantity

Dried skimmed milk powder

1 tablespoon (15g)

Double cream

1 tablespoon (15g)

74

Crème fraiche

2 tablespoons (30g)

113

Butter

1 teaspoon (5g)

37

Olive oil

1 teaspoon (4g)

36

Cheddar cheese

25g

104

Mayonnaise

1 tablespoon (15g)

104

Dates

4 medium (30g)

81

Jam

1 tablespoon (20g)

52

Sugar

1 teaspoon (5g)

20

Honey

1 tablespoon (18g)

52

being identified and a reduction of £300,000 spent on nutrition supplements by GPs”.9 FOOD FIRST

Increasing the energy density of meals and making small changes can make a massive difference to someone identified at risk of weight loss and undernutrition. The following advice can be given to increase calorie and nutrient content without increasing the amount of food eaten. However, it is important to note that if someone is still losing weight after 12 weeks of trying some of these suggestions, or experiences sudden weight loss, they should be referred to their GP: • Eat little and often – try to eat three small meals a day with two or three snacks in between, ideally every two to three hours.

(See Table 1 for some suggestions.)

• Fry meat, chicken and fish where possible, or add creamy sauces, batter or breadcrumbs.

• Use full fat, full cream and sugar products to add extra calories – whole milk in place of semiskimmed, butter rather than low fat spreads.

• Add high energy and protein foods such as butter, cream, cheese, or jam to increase the calorie and protein content. For example, stir two tablespoons of crème fraiche into a bowl of soup for a further 113 calories. (See Tables 2 and 3).

• Include nutritious drinks to increase calorie intake, such as milk-based drinks, fruit juice and fortified soups.

Kcals 53

SUMMARY

With an ageing population and increasing numbers of people at risk of undernutrition, we have seen the importance of identifying those at risk and raising awareness of a food-first approach, thus avoiding clinical intervention and the ‘malnutrition carousel’.

It is important to dispel the myth that weight loss is a normal part of ageing. The PaperWeight Armband is an excellent example of a non-intrusive nutritional intervention. It can be helpful in starting a conversation about food and drink intake, which otherwise might be difficult, and offers signposting to further information and advice.

It can be used in a health and social care setting, but has a wider potential and can be used by family members, domiciliary carers, community pharmacists and volunteers at community groups, such as lunch clubs and church groups.

A food-first approach goes against ‘healthy eating’ messages, but is the best way to encourage food and drink intake in those at risk of undernutrition. The final words go to Alf, an 82-year-old man, whose malnutrition was identified through the PaperWeight Armband. He says, “I’ve just started taking notice of what I’m eating, building myself back up again. When I want to put on weight, I start eating things you’re not supposed to eat when you are slimming and I have the blue milk, which I prefer anyway.”6 www.NHDmag.com May 2019 - Issue 144

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SOCIAL CARE

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

REFERENCES Please visit the Subscriber zone at NHDmag.com

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TRANSFORMING THE LANDSCAPE OF ONS PRESCRIBING IN THE HIGHLANDS In common with most NHS posts, my role encompasses a number of different but complementary components. My job title appears to suggest that I only work with care homes when in fact I also work with care at home services, unpaid carers and I have the organisational lead for ONS prescribing and the negotiation, implementation and monitoring of our enteral feeding contract. Plenty to keep me busy.

In 2018, the growth in use of ONS products across Scotland is reflected in a report from a national short life working group.1 It was no different in Highland and our multidisciplinary prescribing group (including representatives from dietetics, pharmacy, SLT, GP and nurse prescribing) grappled with the best way of tackling the variation in use, the appropriateness of prescribing and the escalating cost to the organisation.

AIMS AND PROCESS

We started by taking a number of steps to try and improve consistency in the rationale for prescribing ONS. After extensive consultation, we reached agreement that we would progress to: • proactively promoting a food-first, person-centred approach, which we have since built into our MUST care plans to reinforce a change in clinical practice; • offering patients self-management advice and literature as well as redirecting people to purchase overthe-counter ONS if they did not meet the criteria to have them on prescription (not ACBS); • recommending that prescribers stop the use of high energy, low volume (HELV) products, such as puddingstyle products, with some clinical exceptions, eg, liver, renal and some paediatric cases;

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• developing a revised, much restricted ONS prescribing formulary, with a preference for the use of ‘shake-style’ products, where patients were able to reconstitute products themselves; • stopping the use of ONS in all care homes.

COMMUNICATION AND FEEDBACK

All information about the food-first approach, associated literature, formulary changes and HELV products now sits on a treatment and medicines (TAM) digital app, which has been well received by prescribers. Regular updates are communicated out to prescribers to reinforce the change in practice needed to reduce the use of ONS and associated costs.

I am delighted to say that we had no complaints about the above from GPs, nurse prescribers, care home managers, dietitians, or patients themselves. We did however complete a mitigated risk assessment, to provide assurance to The Board, given the extensive change in practice across all areas.

As with all transformational change, there were a few people who were reluctant to implement an agreed change to practice. However, assurance from executive board members encouraged us all to forge ahead. It is reassuring to all that 18 months down the line, we have no evidence of any detriment to people

SOCIAL CARE

Reliance on prescribed ONS is putting a burden on health budgets and must be proactively challenged.

annual savings (>£300k) for all ONS products being prescribed for adults.

CONCLUSION

This transformational piece of work has been hugely successful and continues to be embedded and monitored. The model used for this work is transferable to other areas of prescribing practice and is now being replicated in areas of continence and tissue viability.

It has been widely publicised in local and national media2 and is recognised by colleagues across Scotland, with many other boards keen to replicate our results. Poster presentations were selected for: the annual NHSH R@D conference in 2018, focused on the CMOs theme of Realistic medicine;3 EFAD 2018, in Rotterdam; and the NHSS R@D conference in November 2018.

Reliance on prescribed ONS is putting a burden on health budgets and must be proactively challenged. We encourage others to be bold in supporting and delivering a truly person-centred food-first approach across health and social care settings and to return to the basics of good dietetic practice by promoting nutritional care, which is appetising and maximizes health, wellbeing and social interaction at mealtimes.

stopping ONS, or using a food-first approach.

Care home managers and owners are happy to support our approach too and many have commented that the change hasn’t cost more for catering budgets; it has saved staff time managing the use, administration, storage and recording of ONS; residents prefer to take fortified food and drinks than take ONS (there was a great deal of waste previously); and quality of life has improved.

MONITORING AND RESULTS

For anyone who has tried to understand or manage trends in ONS prescribing, the need to have a robust set of data is paramount. When I was asked to take on this role several years ago, this was certainly lacking and it wasn’t just a Highland problem. The national short life working group started to develop a standardised dataset for Scotland, which has since transformed our ability to scrutinise, monitor and take focus the work. It has also greatly improved the understanding and engagement of clinical groups, who have the greatest influence on the use of these products.

The quarterly use and spend of HELV products has dramatically reduced and sits within an overarching picture of recurrent

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A DAY IN THE LIFE OF . . .

A DIABETES DIETITIAN

My day begins, just like other busy working mums, getting up at 5.45am, walking Poppy the dog, preparing breakfast, making packed lunches and dropping my son at nursery.

Ruth BarclayPaterson NHS Ayrshire and Arran Ruth has been a Diabetes Dietitian for five years, with previous experience in Community and Acute. Ruth is currently completing a Masters in Health and Wellbeing.

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I arrive at work for 8.30am. Over a coffee, I check my emails, diary, print off my clinic list and plan my commitments for the day around appointments, triage, new referrals, team meetings, phone calls, liaising with other healthcare professionals and clinical supervision. In addition to ongoing professional education updates for patients, staff and students, I also try to plan time for ongoing service development projects.

My aims as a diabetes dietitian are to help patients understand their diabetes and provide education on how different foods eaten can affect their bodies and impact on their diabetic control, quality of life and general health. I also want to highlight the importance of integrating diet, lifestyle and medications successfully, to help prevent micro and macro vascular complications.

My day with NHS Ayrshire and Arran begins with either a clinic or group session. The clinic session plan allows for a variety of joint working with diabetes specialist nurses and consultants, as well as 1:1 dietetic-only sessions. Today starts off with a joint clinic in collaboration with the Diabetes Specialist Nurses. Typically, these clinics have four complex patients, where the multidisciplinary-team approach is key to encouraging selfmanagement and acknowledgement of the emotional distress these patients are often experiencing as a result of living with their diabetes.

Actively listening is paramount.

Hearing the patient’s story and having an open mind about how this affects their ability to make dietary and lifestyle

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choices that then impact on their blood glucose control, is vital. A patient’s life with diabetes is still as busy as everyone else’s, with the addition of a long-term condition to manage. A case example is that of a 28-year-old patient not taking insulin as a result of their fear of hypos.

This patient consistently runs with blood glucose levels in the hyperglycaemic range and has had multiple Diabetic Ketoacidosis (DKA) admissions in the past. Treatment involves the whole MDT team with input from psychology services. All clinical interventions are documented onto our electronic system, SCI Diabetes, and recorded in patient contact statistics.

I often have to be creative and adapt my solution-focused approach by using evidenced-based diabetes nutritional information and applying it to clinical practice. A technique I use is agreeing a goal plan in collaboration with the patient, tailored to diet, lifestyle and diabetes management goals.

DIETETIC-LED CLINICS

Afternoon clinics tend to be dietetic led. Weight management and carbohydrate awareness/counting are the most common clinical themes. An interesting patient I saw recently had a diagnosis of Type 2 diabetes and was desperate to lose weight. Her mobility was significantly reduced due to a knee complaint and associated pain. Her BMI was over 35kg/m2 and she wished to use a liquid meal replacement for breakfast, but was unsure how to manage her twice-a-day insulin regime.

After assessment of her current and

A DAY IN THE LIFE OF . . .

My day with NHS Ayrshire and Arran begins with either a clinic or group session. . . . . . . As a diabetes dietitian, seeing patients achieve long-term personal goals is truly rewarding

planned carbohydrate intake, insulin titration advice was provided to minimise the risk of hypoglycaemia. Furthermore, this dietary education helped the patient understand the role of carbohydrate in her diet and associated insulin requirements, as well as the insulin mode of action. Over a six-week period with regular telehealth reviews, the patient lost over 7kg. She was so happy that she could touch her toes for the first time in years!

As a diabetes dietitian, seeing patients achieve long-term personal goals is truly rewarding.

CARBOHYDRATE COUNTING

Teaching carbohydrate counting is undoubtedly my favourite intervention. Practical sessions are offered on a 1:1 basis and also as part of the oneday structured education programme, ‘Better Regulation Using Carbohydrate and Insulin Education’ (BRUCIE). Patients are given the tools to manage the multiple factors (activity, alcohol intake, working patterns and mealtimes) that can affect blood glucose control and overall insulin requirements. The practical sessions involve weighing out foods, calculating the carbohydrate content based on the portion served and matching insulin doses based on insulin-tocarbohydrate ratios. We continually get feedback from our patients that they feel empowered

by learning how to do this, as it gives them flexibility with food and dietary choices. One patient commented on Care Opinion referring to BRUCIE: “The course revolutionised my blood sugar monitoring.”

TELEHEALTH ON DIET AND DIABETES

My role includes other duties too, including keeping up to date with latest guidelines – In March 2018, new evidence-based guidelines were published by Diabetes UK for the treatment of diet and diabetes. I’m also progressing phase 2 of a telehealth project: ‘Telehealth on Diet and Diabetes’ (TODD), designed to facilitate diabetes and dietary self-management and dietary behaviour change (in order to create increased dietetic review capacity) within the diabetes dietetic service. The TODD project aims to improve patient lifestyle outcomes and patient contact on a more regular basis with diabetes specialist dietitian.

Additionaly, I normally input into Practice Placement C for student dietitians. I’m a dietetic representative on the Area Allied Health Professions Professional Committee and my other key areas of interest include behavioural change techniques, capturing patient outcome measures and dispelling the pseudoscience and myths associated with diet and diabetes. It’s usually a busy day in the life of for me! www.NHDmag.com May 2019 - Issue 144

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CRAVING FOR CHOCOLATE Easter has been and gone. Spring is fast heading into summer, but as I write this, there are still chocolate eggs seemingly everywhere! I find them hard to resist. Chocolate in general is hard to resist, but what if your dietary requirements mean you can’t eat it?

Louise Robertson Specialist Dietitian

The milk content in milk chocolate vegetarian menus and supermarkets is a problem for some, including for promoting vegan ranges. New foods people with milk allergies, or for those have arrived on the supermarket who have galactosaemia and can’t shelves, such as Jackfruit which can be metabolism galactose (found in lactose). made into a type of pulled-pork dish, Children and some adults with PKU vegan cheese made from coconut oil, (requiring a very low-protein coconut yoghurts and plant-based diet) can’t have chocolate milks including nut, rice and either, as it contains too coconut milk.

What have all the much protein for them.

Milk-free chocolate foods got in common?

Those who follow a vegan diet will be Well, if you look at the is also often lower in avoiding milk chocolate, nutritional labels you protein so could be but some businesses, will see that they are all incorporated into the having cottoned on to fairly low in protein.

As a metabolic the rise of veganism, diets of adults with are starting to provide dietitian who looks PKU and counted into more suitable products after people who have their protein allowance to have low-protein and foods. There over holiday times, has certainly been an diets to manage increase in the amount their conditions, this particularly is exciting to see, as of vegan and free-from during Easter. it offers these patients chocolate available on supermarket shelves. This more food choices directly is good news for children and from the supermarket. But for adults with milk protein allergy, those who have recently chosen to people with lactose intolerance and people become vegan, they need to be educated with galactosaemia. Milk-free chocolate about trendy low-protein vegan foods, as is also often lower in protein so could such foods need to be balanced out with be incorporated into the diets of adults protein sources such as beans, lentils and with PKU and counted into their protein chickpeas. allowance over holiday times, particularly The good news is, Easter time during Easter. needn’t be a chocolate-free zone from Veganism is obviously becoming now on. And before we know it, all more popular. I have seen well-known the Christmas chocolates will be back pub chains advertising their vegan and on the supermarket shelves!

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

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Coming in the June/July issue: • Cow’s milk allergy

• Ileostomy & colostomy management • IBS/IBD

• Dementia: healthty eating to reduce the risk • The flexitarian diet • ONS prescribing

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