Network Health Digest - Aug/Sept 2019 by NH Publishing Ltd

N at e in nl m s o .co ue g ss a li m ta D gi H d i .N D w H ww

The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

Aug/Sept 2019: Issue 147

EATING DISORDER RECOVERY

FOLLOW-ON FORMULA MILK SETTING UP A DIETETIC SERVICE PRE-OPERATIVE NUTRITION PRETEEN OBESITY STOMA CARE ONS PRESCRIBING

ULTRAPROCESSED FOODS Pages 8-10

NHD and British Lion eggs competition WINNING ARTICLE

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)

WELCOME How much information do you take in from the media? How do you process that information? What impact does that have on you and your life and on the decisions you make? Throughout this double issue, we discuss and share thoughts and views regarding the influence of the media on several topics, including eating disorders and public health messages. Emma Berry starts us off by looking at the research and evidence surrounding the claims that processed foods may be bad for health. She discusses what constitutes an ‘ultra-processed food’ and how messages that hit the media impact on the public. Social media affects current dieting culture too, and Nikki Brierley, specialist dietitian in eating disorders (ED), talks us through the potential impact associated with the weight-loss industry and the social norm of sharing weight-loss advice, tips and inspiration. Continuing with the ED theme, our Cover Story this month is an overview of the roles and responsibilities of a specialist dietitian involved in this area. Oana Oancea highlights the recovery stages in an inpatient setting and looks at the relationship between the dietitian, patient and the patient’s family/carers. We always aim to give you varied articles on wide-ranging topics and this issue is no different. Paula Hallam returns to focus on follow-on formulas and discusses the evidence and recommendations around these products. We also welcome back Farihah Choudhry with an article delving into the specific realms of preteen or childhood obesity and what role a parent might play in this.

FROM THE EDITOR

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

In our clinical features this month, Harriet Smith discusses the importance of pre-operative nutrition and the current advice for this patient group. Rebecca Gasche takes a look at the key aspects of care for patients with stomas, which links in nicely with Louise Edwards report on setting up a dietetic service for this particular patient group. Whilst it can be a challenge and may not always be feasible to develop a new patient service in the NHS, it can be a highly rewarding and positive experience for all involved. Our NHD/British Lion eggs writing competition came to a close at the beginning of July and, in this issue, we feature the winning article by dietetics student Laura Kaar. Laura impressed the judges with her interesting and well-researched look at the nutritional composition of eggs and the wide range of health benefits associated with including eggs as part of a balanced diet. And there’s more too, as Martha Hughes comments on ONS prescribing for a If you have important news or clinical need and research updates to share with NHD, or Laura Sexton gives would like to send a letter to the Editor, us her Day in the please email us at Life of a community info@networkhealthgroup.co.uk nutrition support dietWe would love to itian. So much to read hear from you. for your summer hols! Emma www.NHDmag.com August/September 2019 - Issue 147

11 COVER STORY Eating disorder recovery 6

News

Latest industry and product updates

8 ULTRA-PROCESSED FOODS

36 Stoma Care Ileostomy/colostomy

15 Eating disorder: case study The impact of dietary advice

management

21 Follow-on formula Advice and appropriate useEatwell Guide Check the label on packaged foods

Use the Eatwell Guide to help you get a balance of healthier and more sustainable food. It shows how much of what you eat overall should come from each food group.

Each serving (150g) contains

Energy 1046kJ 250kcal

13%

Fat

Saturates Sugars

3.0g 1.3g LOW

LOW

Salt

34g 0.9g HIGH

of an adult’s reference intake Typical values (as sold) per 100g: 697kJ/ 167kcal

Eat at leas t5

Chopped t omatoe s

Whole grain cereal

Bagels Whole wheat pasta

Porridge

Rice

Lentils

Tuna

Plain nuts

Beans lower salt and s ugar

Chick peas

Eat less often and in small amounts

Spaghetti

L o w f at s o f t ch e es e

n Leaince m Semi skimmed

milk

Crisps

Sauce

Cous Cous

Frozen peas

29 Preteen obesity A parent's role

Limit fruit juice and/or smoothies to a total of 150ml a day.

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Potatoes

gar and su salt fat, ed s dd drate ohy sa arb les yc

po rtio ns

s of ble ty ta rie ge va ve ta n

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Water, lower fat milk, sugar-free drinks including tea and coffee all count.

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25 PRE-OPERATIVE NUTRITION

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39 DEVELOPING A DIETETIC SERVICE

prescribing Lower fat d sprea

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Oil & spreads

Choose unsaturated oils and use in small amounts

fat wer tions se lo Choo ugar op s lower

Per day

2000kcal

45 A day in the life of . . . A community

2500kcal = ALL FOOD + ALL DRINKS

Source: Public Health England in association with the Welsh Government, Food Standards Scotland and the Food Standards Agency in Northern Ireland

33 EGGS: FRIEND OR FOE? NHD/British Lion eggs competition winner

nutrition support dietitian

47 Dietitian's life Reflecting on Dietitians Week

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

F o

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 August/September 2019 - Issue 147

@NHDmagazine ISSN 2398-8754

N r

A * * †

Cow’s Milk Allergy

doesn’t always end at one year

Trust Neocate Junior to support her next step

Neocate Junior: The unique Amino Acid-based Formula for children with Cow’s Milk Allergy over one year of age. Best tasting†

Flexible

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Neocate: The UK’s No. 1* Amino Acid-Based Formula For further information please visit www.neocate.co.uk or to request a sample**, please call 01225 751 098 (UK) This information is intended for Healthcare Professionals only. Neocate Junior 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 date of publication, July 2019. *IMS Data April 2019 **Product can be provided to patients upon the request of a Healthcare Professional. They are intended for the purpose of professional evaluation only. † Data on file, May 2016 & January 2017 ‡ Clinical data on file, May 2016 Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ

Excellent compliance‡

NEWS CLINICAL HCPC SUPPORTS REFLECTIVE PRACTICE ACROSS HEALTHCARE Reflective practice plays an important role in healthcare, as affirmed by the HCPC, along with the chief executives of other healthcare regulators, in a signed joint statement:

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

Network

Health Digest call

01342 824073.

‘Benefits of becoming a reflective practitioner – outlining the processes and advantages of good reflective practice for individuals and teams.’ The statement states that reflection brings benefits to service user, by fostering improvements in practices and services and assuring the public that healthcare professionals are continuously learning and seeking to improve. Information is given on how to get the most out of reflective practice, including having a systematic and structured approach with proactive and willing participants. It makes clear that any experience, positive or negative and however small – perhaps a conversation with a colleague – can generate meaningful insight and learning. Multidisciplinary and professional team reflection is viewed as an excellent way to develop ideas and improve practice. For the full statement, visit: www.hcpc-uk.co.uk/globalassets/news-and-events/benefits-of-becoming-a-reflectivepractitioner----joint-statement-2019.pdf

THE NHS LOW CARB PROGRAM Diabetes Digital Media’s Low Carb Program1 is a 15-week structured behaviour change programme for people with Type 2 diabetes, prediabetes and obesity. Launched in 2015. A recent paper published in 2018 in the Journal of Medical Internet Research2 has proven that a digitally delivered low carbohydrate Type 2 diabetes self-management program is effective in improving glycaemic control, weight loss and reducing hypoglycaemic medications. The BDA has recently released a positive review3 of the NHS Low Carb Program App, giving a comprehensive overview. The Low Carb Program App is available via the NHS library4 and it currently carries a ‘No Badge’ status, which means it meets NHS quality standards for safety, usability and accessibility. It has also gained QISMET approval, meaning it can be prescribed on the NHS.5 References 1 Diabetes Digital Media’s Low Carb Program: https://ddm.health/ 2 Laura R Saslow, Charlotte Summers, James E Aikens, David J Unwin. Outcomes of a Digitally Delivered LowCarbohydrate Type 2 Diabetes Self-Management Program: 1-Year Results of a Single-Arm Longitudinal Study. JMIR Diabetes 2018 (Aug 03); 3(3):e12. https://diabetes.jmir.org/2018/3/e12/ 3 British Dietetic Association (2019). Review of the NHS Low Carb Program App: A Diabetes Dietitian’s Perspective. Paula Gallon, Specialist Diabetes Dietitian, Solihull Community Diabetes Service on behalf of the BDA Diabetes Specialist Group 4 www.nhs.uk/apps-library/low-carb-program/ 5 www.lowcarbprogram.com/nhs/

www.NHDmag.com August/September 2019 - Issue 147

NEWS STUDY LOOKS INTO HOW FATHERS CAN INFLUENCE THEIR CHILDREN’S DIETS A new study1 has looked into how fathers’ parenting behaviours contribute to the development of children’s dietary behaviours and subsequent weight outcomes. The Extended Infant Feeding Activity and Nutrition Trial Program study is the first to investigate whether paternal self-efficacy influences the dietary intakes of young children. Results of the study showed that associations between paternal self-efficacy and children’s dietary intakes are present at a young age. It also showed that paternal self-efficacy for promoting children’s obesity-protective dietary intakes reduced over time and was influenced by the father’s education and qualifications. Higher and/or sustained paternal self-efficacy is associated with fathers’ education and is important in promoting children’s obesity protective dietary intakes. The study recommends that future family interventions should consider how to maintain and/or improve paternal self-efficacy to positively influence children’s healthy food intakes in early childhood. 1 https://ijbnpa.biomedcentral.com/articles/10.1186/s12966-019-0814-5

POSITIONING OF SUPERMARKET FOODS ONLINE CAN HELP REDUCE SATURATED FAT INTAKE Interventions to reduce the saturated fat (SFA) content of food purchased online may help reduce SFA consumption and lower cardiovascular risk. A recent RCT examined the effects of altering the default order of foods selected during an online shopping experiment. Purchasers were also offered food swaps with less SFA content. Between March and July 2018, UK adults, who were the primary grocery shoppers for their household, were recruited online and invited to select items in a custom-made experimental online supermarket, using a 10item shopping list. 1240 participants were evenly randomised and 1088 who completed the task were analysed (88%). Participants were 65% female. Compared with no intervention where the percentage energy from SFA was 25.7%, altering the order of foods reduced SFA by 5% and offering swaps by 2%. The combined intervention was more effective than swaps alone (3.4%). Environmental-level interventions, such as altering the default order of shopping items in online supermarkets, may be a promising way to improve food purchasing. For the full results visit: www.ijbnpa.biomedcentral.com/articles/10.1186/s12966-019-0810-9.

www.NHDmag.com August/September 2019 - Issue 147

PUBLIC HEALTH

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

ULTRA-PROCESSED FOODS: NEWS HEADLINES AND NUTRITION In May 2019, The British Medical Journal (BMJ) published a research article on ultra-processed foods and the link to all-cause mortality.1 The research article adds to a growing body of evidence that claims processed foods may be bad for health. So, what constitutes an ‘ultraprocessed food’ and how do messages that hit the media impact on the public? The BMJ article, by Rico-Campa et al (2019) followed a cohort of 19,899 University graduates aged between 2091 years.1 This received media attention across the UK, including from the BBC and in The Guardian.2,3 The participants were followed up every two years, between December 1999 and February 2014, gathering food frequency data from web or postal questionnaires. The study states that it was a dynamic cohort, so recruitment to the study was ongoing throughout the data collection period. The data collected from the questionnaires was then used to work out the consumption of ultraprocessed foods by participants. Foods in the questionnaire were grouped into four categories1 dependent on their processing (based on NOVA1): 1 Unprocessed/minimally processed, such as fruits, vegetables, fresh and pasteurised milk, herbs, spices. 2 Processed cooking ingredients, such as salt, sugar, oils and butter. 3 Processed foods, such as cheese, fresh bread, salted nuts and canned vegetables. 4 Ultra-processed foods, including sodas, sausages, fruit yoghurts, bottled fruit juices, sweets and alcohol. The researchers focused specifically on the ultra-processed foods (listed as group 4 above). These foods are defined as ultra-processed as they have a high energy/calorie content, low nutritional

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value and generally contain added sugar, salt and additives.1 When carrying out the data analysis, the researchers did take into consideration influencing factors such as smoking, exercise, age and BMI and adjusted their findings to account for these factors. The research found that an increased consumption of ultra-processed foods was linked to an increased risk of death. However, the actual number of participants who passed away during this study was 335, with the main cause of death being cancer (164 deaths out of the total 335). Although this study has many strengths, like the high number of participants and a high retention rate (90%), the results should be taken with a healthy dose of caution. Food frequency questionnaires can be at risk of bias (as many people may not be able to accurately record their food intake from a two-year period – understandably so). However, these food questionnaires were originally developed in the 1990s and would not accurately capture our changing food landscape, which has been changing rapidly, with food manufacturers following the latest food trends when developing new products. The researchers do state that this is a limitation, as the questionnaire did not include information on energy bars, energy drinks, health or slimming products and more. It is also important to say that as the participants were all university graduates, the research

PUBLIC HEALTH

The researchers focused specifically on the ultraprocessed foods. These foods are defined as ultra-processed as they have a high energy/calorie content, low nutritional value and generally contain added sugar, salt and additives.

results may not provide a full example of the relationship across a wider population, as socioeconomic status was not adjusted for.1 Although this study may give important information about a potential relationship between ultra-processed food and death. It does in no way prove that ultra-processed foods can cause a person to have an increased risk of dying. There are numerous reasons as to why people may choose to eat a lot of ultraprocessed foods, eg, a lack of time or knowledge in cooking, being too unwell to cook fresh foods, or because they taste good. There are also many foods which are branded as a healthier option, which would still fall into the ultra-processed category, eg, protein bars, low-calorie cake bars and low fat ‘healthier’ yoghurts. It is incredibly hard to pinpoint a causal relationship in nutrition studies, as people’s diets are extremely varied and can change over time. Individuals often don’t eat the same food every day and food is closely linked to socialising and celebrations, so finding the effects of a specific food, or food group, on health is incredibly challenging. MIXED MESSAGES

The link between processed foods and health is not necessarily new. The International Agency for Research on Cancer (IARC) announced the

link between processed meats and cancer back in 2015.4 There have been many headlines written about sugary beverages and the UK’s sugar tax since it was announced in 2016.5,6 However, these articles often discuss obesity, health risks and what a healthy diet should look like, but is this actually helping? The current UK guidelines on a healthy diet for the public are provided by the Eatwell Guide, but is it fair to promote the Guide as a ‘healthy diet’ when some people can’t afford the fresh food that is recommended? Often people can’t access this food, or are unable to cook it for various reasons.7,8 Some people say that they do not even feel they know what ‘healthy’ food or a ‘healthy’ diet actually is, due to so many mixed nutrition messages.8 People may categorise foods into ‘good’ and ‘bad’, ‘healthy’ and ‘unhealthy’, which doesn’t necessarily stop people from eating certain things, but can result in feelings of guilt.9 Food guilt is the feeling of guilt after eating, normally linked to eating a food which is perceived to be unhealthy (characterised by a high fat, salt or sugar content and likely to fall into the ultra-processed food category). It is likely that these foods have been given the label of being bad for you through public health messages, or have the perceived risk of making us gain weight by eating them.9 However, this www.NHDmag.com August/September 2019 - Issue 147

PUBLIC HEALTH food guilt and pressure to eat only ‘healthy’ foods can have negative effects on overall health and nutritional status.10 One example of a negative effect on health is that individuals could have disordered eating leading to the development of orthorexia.* Orthorexia is a relatively new eating disorder, initially discovered in 1998 and is not a formally recognised condition.11 The condition generally involves restricting food intake to foods deemed healthy or safe – often cutting out entire food groups from the diet, such as sugar, dairy, meat or carbohydrates.12 Eliminating food groups can impact on nutrition and so result in malnourishment.11 Conversely, food guilt and trying to eat healthy foods can result in weight gain.10 For individuals trying to ‘eat healthier’, or lose weight, eating a food they perceive as unhealthy, such as cake, may then result in negative emotions. Restraint with foods perceived as unhealthy has been linked to weight gain and disordered eating.10 Therefore, choosing to avoid these foods may result in individuals having poorer physical and mental health.10 *For more on orthorexia, please see Alice Fletcher’s article: Orthorexia: an eating disorder of the modern age? NHD Feb 2019, issue 141, pp 22-26, available in the Subscriber zone at www.NHDmag.com INTUITIVE EATING

It has been suggested that an intuitive eating** approach may be a better way of promoting healthier diets. This may be an alternative to the current culture of promoting unprocessed foods and dietary restraint as being superior for health.10,13,14 Our current health messages on reducing obesity and following a healthy diet may be causing more problems than they are solving. Suggesting that some foods are unhealthy or less healthy than others, can create a complex

emotional relationship to the foods we eat. Often having foods that we, or our friends and family, may deem as unhealthy will result in people feeling they have to “make up for it later,” or they will be “extra good tomorrow”, rather than just enjoying the food they are eating. This stems from a fear of becoming obese, which also then means that individuals who perceive themselves as at risk of this, could have resulting negative mental health symptoms.10 This may be disproportionately affecting certain groups of society, as often the foods deemed unhealthy are cheaper and available in areas with limited access to fresh food. We are setting nutritional messages and guidelines that not everyone is supported to achieve. **For more on intuitive eating, please see Jess English’s article in NHD May 2019, issue 144, pp 35-38 available in the Subscriber zone at www.NHDmag.com. CONCLUSION

If we remove the message of certain foods being labelled healthy or unhealthy and, instead, promote a diet of diversity, then this could be a positive step in helping achieve better nutrition for the population as a whole. By changing the message, we could remove the fear of weight gain that we now have as a society, reduce the risk of disordered eating and support more of our population in having better nutrition. Although there is a fear that ultra-processed foods are bad for health, eating any food or food group to a high frequency will not be ideal for human health, but fearmongering from the media can often cause more harm by reinforcing the idea that all ultra-processed foods are bad all of the time. This may lead to confusion as to what a healthy diet actually is and what it consists of. Ultimately, messages on how we can promote health through a varied diet need to be clear and consistent. Avoiding certain food groups is not the answer.

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COVER STORY

THE CHALLENGES OF EATING DISORDER RECOVERY This article depicts the roles and responsibilities of a specialist dietitian in eating disorders (ED), highlighting the recovery stages in an inpatient setting and presenting an overview of the relationship between the dietitian, patient and the patient’s family/carers. Dietitians have a multifaceted role in the treatment of an ED, with nutritional intervention being an essential part of the treatment for patients. Any job in mental health can be very demanding and requires high resilience, but a specialist dietitian in ED can face even more challenges, due to the complex needs and confrontational behaviours of this patient group. In most ED cases, other disorders can co-occur, such as depression, anxiety, substance/alcohol abuse, self-harming, borderline personality disorder and obsessive-compulsive disorder. Working with ED patients requires a solid comprehensive level of knowledge, and if the main responsibility of the dietitian is to focus on food-related problems, then sometimes the job requires a skill mix. Enhanced communication, counselling and motivational interviewing skills are all important. The job can be personally and professionally exhausting. To avoid this happening, the dietitian should have a very clear set of boundaries in place when working with a patient who is suffering with an ED.1 Boundaries are exceptionally important tools implemented during the patient’s treatment.

Oana Oancea Registered Dietitian, Priory Hospital

MAXIMISE COMMUNICATION

A significant part of the treatment will involve negotiation, as communication plays a very important role. It will have a huge impact on an inpatient’s day-to-day life. Sometimes, the way you are delivering a message can make all the difference as to whether the patient becomes distressed, selfharms, has suicidal thoughts, and/ or rising anxiety levels.2 Being part of a multidisciplinary team (MDT), the dietitian should be aware that if communication fails with the patient, it can have an impact on the whole ward. Some of the patients will express their frustration, anxiety, or anger on the other staff members and very often on other patients. I have found that the biggest catalyst to affect the whole dynamic of the ward can be the weight-gain meal plan mentioned later in this article. ED can make a patient become manipulative, sneaky and secretive, causing rifts in the MDT. In some cases, it may be useful for the dietitian to be accompanied by a chaperone, someone who the patient feels close to and comfortable with.3 It’s very important that scheduled one-to-one sessions are kept and the times of these

Oana has a keen interest and specialises in eating disorder dietetics. She currently leads CAMHS, Addiction and Eating Disorder Unit in Priory Hospital, Chelmsford, where she has been for two years.

REFERENCES Please visit the Subscriber zone at NHDmag.com

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COVER STORY respected. If the dietitian is late for whatever reason, the patient will feel “unworthy” and anxieties will build up. “MY DIETITIAN SHOULD BE MY ROLE MODEL”

Despite all the obstacles within dietitian-patient communication, patients have a clear image of how they expect the dietitian to behave. Feedback questionnaires show that ED patients are most often expecting the professional to have the following characteristics: open-minded, trustworthy, a good listener and assertive. From the same questionnaire, I found out how important it is for the dietitian to look healthy. When I raised this aspect with my patients, the most common answer was along the lines of: “I can’t trust someone’s advice if he/she doesn’t look after his/her own body. My dietitian should be my role model.” STAGES OF TREATMENT IN INPATIENT SETTINGS

Admission • Each patient admitted to the ward follows a 7-Days Meal Plan Protocol (three meals and three snacks spread throughout the day). The 7-Days Protocol can start from 500kcal up to 1800Kcal depending on how high the risk of refeeding syndrome is. The amount of calories will be decided after a rigorous assessment involving the whole team. • Weight and the bloods will be checked every day early in the morning for the first seven days. • At this stage, negotiation will be minimal and one-to-one sessions are scheduled daily for the first week. • The amount of calories and the gradual increase for the seven days will be made known to the patient in the first session. No further discussion will be held about calories until the patient is discharged. • Each patient will be seated for the beginning at Table One, which is for patients who are not able to finish their meals in time and who are deeply set in their ED behaviours. • Until the patient reaches the next stage of treatment, I use the one-to-one sessions to build trust and to focus more on the patient’s motivation, to explore feelings around hunger/fullness and find out about metabolism. We analyse together the irrational thinking about food and the 12

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patient’s looks. During the first week of admission, I try to minimise the typical behaviours derived from the illness they suffer from. Restoration Stage The topics I address in the Restoration Stage are: • meal plan structure; • teaching the patient to communicate with his/her body again; • showing the patient how to trust his/her primary instincts again; • supporting the patient to free himself/herself from anorexic thoughts derived from his/her illness; • working with facts and strongly advising the patient to keep journals. Patients can keep journals about: • activity level on the ward or on the hospital’s grounds; • feelings related to any activity which involves food (meals, groups, meals supervision, etc); • reflective processes and weekly nutritional goals and challenges. Pre-maintenance Stage The word which can best describe my work at this stage is ‘exposure’. I hold cooking groups, fear-food activities, snack and lunch out of the hospital during one-to-one sessions or in groups of up to four patients, and takeaway activities. The aim of the groups is to undo the false beliefs caused by anorexia in order for patients to regain their confidence and to develop the important social skills needed for them to integrate back into the world after discharge. In addition, the groups help patients to stop the obsessive caloric counting, the monitoring or precise measuring of foods, or the obsessive labelling checking. Patients will learn during this stage how to portion food items. The scales will be eliminated gradually, which is part of the patient’s goals. The social eating activities make them aware of the benefits of social life and the importance of independence. They aim to help minimalise the feeling of being judged or

COVER STORY

The purpose of guidance is to allow the patient to normalise their eating patterns and not to strictly follow a meal plan.

watched, and to help patients feel comfortable around other people. The fear-food activity is combined with mindful eating and each fear food, although not part of the current meal plan, will be eaten before the weighing day to show to the patient that it will not cause a massive fluctuation in his/her weight. Every week we conquer a new food item, one by one, until the patient is ready to integrate it in his/ her current meal plan. It is important that the fear food is associated with a nice memory from the past and for the patient to reconnect with this warm feeling in the present. Most of the patients will describe this experience as liberating. They feel proud and a whole new world opens up before them. Cooking groups involve planning and shopping for ingredients. The patients are in charge of choosing recipes as long as they respect the Eatwell Guide model. Another challenge is to advise patients to taste the food while cooking. This helps them rediscover savoury food, to make it much nicer through adding herbs and spices, and adjust the overall taste to their recently rediscovered likeness. Patients reported that the exposure work gives them a feeling of accomplishment. Their anxiety reduced gradually and they are able to rebuild their relationship with the family in the kitchen. During group sessions, patients are able to share tips and experiences, encourage each other, find common tastes and preferences and (re)define their personal taste. The exposure work during the final stages offers the patients the possibility to take some control back (choosing the recipes, the restaurant, the takeaway food, etc). Patients also

report before discharge that the groups boost their confidence and help them develop a more flexible approach towards food. Maintenance Stage The purpose of guidance is to allow the patient to normalise their eating patterns and not to strictly follow a meal plan. If they miss an item, they can make up for this later in the day, or they can choose to replace it with an alternative. During this stage, the patient is taking ownership over what they do or do not eat. Thus, if they choose not to have an item and then not to have it later on, the risk they are taking is that their weight is likely to drop. If their weight drops below their range, they will need to go back onto a weight-gain meal plan. It is helpful to notice what they are doing, but this is the stage when staff take a step back to allow the patient to make their own decisions around their eating. During this stage too, the patient no longer requires supervision or protocol in relation to supplements. FAMILY â&#x20AC;&#x201C; A GEMSTONE FOR THE RECOVERY

Family is one of the most important and powerful tools in the journey of recovery. Feedback questionnaires show that 65% of our patients would like to recover for their family, but not for themselves. Many patients are very reluctant to let the family get involved in their recovery, especially at the start of the treatment.4 They feel controlled and are scared that the professionals may find out from the family whether or not they followed the treatment while on home leave. In 40% of cases, patients newly admitted to our Springfield ward opt for â&#x20AC;&#x2DC;no sharing www.NHDmag.com August/September 2019 - Issue 147

COVER STORY Table 1: Family trigger statements and positive alternatives to encourage Family trigger statement

Patient interpretation

Alternative positive statement

“Just eat/stop”

It’s that simple

“I understand, it is not as easy as it sounds”

“You are not even trying”

I might as will give up

“Keep working on it, ’you’ve got this”

“You look healthy/well/better”

I am fat/I am no longer ill

“You look happier”

“I can’t believe how much you are eating/your eating has changed”

I’m fat, I’m greedy, I’m normal

“It’s so nice to see your progress”

“Let’s go for a walk”

They think I ate too much

(Don’t get involved)

“This is unfair on your family”

They think it’s all my fault

“It must be hard for you and your family”

How does it taste?

Guilt

(Don’t question this subject)

information’. This is a clear barrier between professionals and family, but a comfortable blanket for their condition. Fortunately, in nearly 70% of cases, patients will change their mind through the admission stage and they will let the professionals start to work with their families. Both family and patient need to learn to balance control, with family members learning to help the patient build confidence in a familiar environment and the patient working towards regaining trust from the family. It is also vital during this process that the dietitian provides all the patient’s family members with a solid education in nutrition. CLINICAL OBSERVATIONS

The family can be a trigger for the patients, with patients reporting that a family member’s comments can trigger the illness. A questionnaire revealed the most common comments that can affect the patients include: “It’s just food”, “Stop it”, “You will feel better after”, “You will look better if you are eating”, and repetitive suggestions such as: “Try this/that”, or “The dietitian said…” (see Table 1). Using negative body language also has a significant impact on the patient. Quite often I observe fissures in the dynamic of the family when it comes to food. One of the factors that can lead to a lack of support from the family towards a patient, is a rigid work schedule. They eat rarely together and they are unable to provide supervision to the patient. The meals they do eat together most often are those during the weekend. Sometimes, the family are not able to offer the full support to the patient because they need to look after other children. 14

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Parents too, can’t always be good role models all of the time (eg, skipping meals or snacks themselves; following weight loss diets at the same time the patient is recovering; combining eating with other unhealthy activities). It is, therefore, very important to understand the whole family dynamic and to take into account each family member’s lifestyle and habits. I strongly advise that at least one of the parents is more flexible with their job when the patient is going on home leave. Mounting evidence from family studies point to increased rates of ED where dysfunctional family systems co-exist. Whilst numerous studies have focused on maternal influences on the development of ED, paternal influences have received far less attention. CONTINUING CARE

Relapse is common amongst recovered anorexia nervosa patients. Studies on relapse prevention with an average follow-up period of 18 months found relapse rates between 35% and 41%. In leading guidelines, there is general consensus that relapse prevention in patients treated for anorexia, is a matter of essence. However, lack of methodological support hinders the practical implementation of relapse prevention strategies in clinical practice.5 Not all the community teams have the necessary resources to be able to monitor and support the patient when discharged from hospital. The lack of resources (eg, staff, training, large caseloads) can lead to a full relapse of the patient within two months. I am left to wonder how we can provide a continuation of care and maintain a patient’s progress once they are back in the community.

CONDITIONS & DISORDERS

EATING DISORDERS: THE POTENTIAL IMPACT OF DIETARY ADVICE Many eating disorders (ED) start after a period of ‘normal dieting’. This raises the obvious question of what are the potential dangers associated with the current dieting culture, weight-loss industry and the social norm of sharing weight-loss advice, tips and inspiration. ED are defined by negative beliefs and behaviours that individuals experience in association with their eating, body shape and weight. This can result in restricted eating, binge eating and/ or compensatory behaviours.1 It is estimated that 1.25 million people in UK have an ED (25% of which are thought to be male), with research suggesting an increasing prevalence of ~7%/year since 2005.2 The impact and consequences of an ED can be devastating, not only for the individual suffering with the disorder, but also for friends and family members, as they often struggle to support them. The development of an ED is understood to be complex, often with a number of different factors contributing, including genetic, psychological and social. A recognised environmental contributor is the sociocultural ideal-isation of thinness and the idea that thin is associated with both beauty and health. This has given rise to dieting and diet talk, currently being viewed as a social norm. It has also created a very lucrative dieting and weight-loss industry, despite the poor long-term outcomes associated with weight-loss diets. It is widely accepted that healthy weight loss can be achieved in the short

term, but is gradually regained by a large percentage of individuals over a longer time frame. With this in mind, it is easy to see how the promotion of weight-loss diets and commencing such diets could potentially increase the risk of developing and maintaining an ED (ie, promote a drive for thinness and fear of fatness).

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-toone and group support.

DIETARY ADVICE

Dietitians are described as, ‘the only qualified healthcare professionals who assess, diagnose and treat diet and nutritional problems’,3 and the title of 'dietitian' can only be used by a suitably qualified individual who is registered with the Health and Care Professionals Council (HCPC), a statutory register of health and care workers, which exists to ‘protect the public’.4 Unfortunately, there appears to be a vast amount of dietary advice provided currently, by individuals who are not HCPC registered, via a variety of sources. This advice seems to largely come from ‘personal experience’ (ie, someone who has apparently improved their own health or appearance through following a specific diet and is sharing advice with others based on this experience), or by so-called ‘experts’ (ie, someone who claims to have a high

REFERENCES Please visit the Subscriber zone at NHDmag.com

www.NHDmag.com August/September 2019 - Issue 147

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CONDITIONS & DISORDERS level of knowledge relating to diet, weight and/ or health, for example, personal trainers, exercise experts, wellness/wellbeing/lifestyle coaches), or by ‘celebrities’ (ie, someone who is famous and providing dietary advice/endorsement). An individual can be fined up to £5000 if they call themselves a dietitian and are not registered with the HCPC. Unfortunately, it is difficult to ascertain clear information on legal enforcement against those who provide

nutritional and dietary advice without adequate training and qualifications to safely do so. This raises the question: does more need to be done to protect the public from potential known risks, which include, but are not limited to, the development of an ED? Below is an illustrative case study that highlights the potential role of the social idealisation of thinness and dietary advice in the development of an ED.

CASE STUDY C1: a 22-year-old female referred to specialist community ED service after presenting to her GP with low mood/depression and anxiety symptoms. Weight 52kg, BMI 19.3kg/m2 She reported dissatisfaction with her body due to recent weight gain of ~4kg over a six-month period and disclosed a restrict binge and purge pattern (self-induced vomiting, exercise and laxatives), which had developed following an initial period of dieting and weight loss. HISTORY OF EATING DIFFICULTIES Childhood C1 described herself as subjectively feeling overweight as a child and compared herself negatively with her smaller and thinner friends. She reported being aware that her mum was unhappy with her own weight and regularly observed her mum’s attempts to lose weight (via attending mainstream weight-loss groups). She described also being aware that her grandad had Type 2 diabetes and raised cholesterol and that he had been advised by a dietitian, nurse and doctor to lose weight and to reduce his sugar and fat intake. She recalled her grandad expressing his concern that other family members could also be at risk of developing diabetes and she recalled that he would regularly encourage them to also lose weight and reduce their sugar intake, so as to reduce their risk. She reported a positive relationship with her grandad, but she worried that he thought she was fat and unhealthy (although he did not express this to her). Adolescence C1 reported becoming focused on her own weight at around 15 years of age, when her mum encouraged her to join her and lose weight together in the lead up to a family wedding. She described enjoying this experience with her mum, who provided praise and encouragement throughout and that they spent more time together going for walks and planning, preparing and eating food. She described experiencing a gradual weight loss (12kg in three months; 68kg, 25.3kg/m2, reducing to 56kg, 20.8kg/m2) by “healthy eating” (as promoted by a slimming group) and increased exercise (mainly walking and also attending an organised exercise class with her mum). She described increased confidence during this time and that she enjoyed the many positive comments from family (including her grandad) and friends when she attended the wedding (BMI 20.8kg/m2). C1 recalled maintaining “healthy eating” and was determined to start college as a “thin and healthy” person. She described feeling anxious about starting college and reported that she felt that if she was thin, she would make friends easier and be more popular. She explained that during her time at college, she strictly followed her previous diet (<1500kcals/day) and increased her exercise (5-6/week, various exercise classes and gym workouts) and reduced her weight further (~50kg, BMI 18.6kg/m2). She described feeling frustrated when her mum raised concerns at her 18th birthday about her “looking too thin” and thought that she might be envious, as she had been unable to maintain her previous weight loss.

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CONDITIONS & DISORDERS Case study continued Adulthood C1 described finding it increasingly difficult to stick with her diet and exercise plan once she commenced university (moved away from the family home and commenced part-time work in addition to studying) and that she started to gain weight and became very fearful of this. She described seeking alternative diet and exercise advice from online sources and commenced training with a personal trainer (PT). She described setting herself a goal weight of 47kg, BMI: 17.5kg/m2. She described achieving this (her lowest reported weight) at 19 years of age, whilst strictly following a low-carbohydrate, no-added-sugar, no-wheat/gluten and no-dairy diet (as recommended by her PT). She reported finding this difficult to adhere to and reported developing a significant fear of weight gain, as she started to subjectively binge on non-allowed foods (mainly chocolate, bread and biscuits). She reported that at this time, if her weight exceeded 50kg, BMI 18.6kg/m2, she would feel “fat and panicky”. C1 reported that she stopped training with the PT, as she disliked not achieving the agreed diet, exercise and weight goals. She reported that after this, she used many different social media outlets and weight-loss apps, as sources of motivation and inspiration to stay focused on her diet and exercise programme. She described not always able to stick to the recommendations and that she continued to experience subjective binges that were increasing in frequency (2-4/week). She recalled that the first time she self-induced a vomit was before a planned return visit home from university (20 years of age). She described that she had been restricting her diet to reduce her weight before seeing friends and family and that she had then binged on “bad” food (high fat, sugar and carbohydrate foods) and due to feeling fat and worrying about how her friends and family would view her, she induced a vomit to get the “bad” foods out of her body. She described feeling shocked by her behaviour and had no plans to repeat it. However, she reported that self-induced vomiting and laxative use became a regular method for her to try and control her weight (3-7/ week). CURRENT EATING DIFFICULTIES ED diagnosis: bulimia nervosa Weight: 52kg (4kg weight gain ~4 months) BMI: 19.3kg/m2 C1 described feeling scared to eat most of the time and reported a significant fear of weight gain and becoming “unhealthy and fat”. She described viewing most food as “bad” and to be avoided, and feeling confused by the many different sources of dietary advice that she had followed. She described avoiding eating until lunchtime (in order to induce “fasting”), eating a salad with lean protein for lunch, followed by fruit and then binging most days on chocolate and biscuits once home from work (followed by a self-induced vomit), eating a “healthy” evening meal (lean protein, vegetable, small serving of wholegrain carbohydrate, <500kcals) and then trying to avoid eating after 7pm (to induce fasting), but that some evenings she would binge and then induce vomiting. She described her aim to avoid sugar, wheat/gluten and dairy and that she wanted to follow a plant-based/ vegan diet, but had been unable to adhere to it. She described feeling guilt and shame at consuming bad foods and that she felt weak and disgusted by selfinduced vomiting and her inability to stop this behaviour. She described daily self-induced vomiting, trying to avoid laxative use (limiting to weekends only) and exercising most days (despite not wanting to). She also described being aware that diet can contribute to mood and mental health and, therefore, being worried had caused her depression and anxiety. She described feeling overwhelmed and confused by the differing dietary advice and knowledge that she had accumulated relating to nutrition, exercise and health from various sources.

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CONDITIONS & DISORDERS DISCUSSION

The illustrative case study (C1) in this article is representative of many individuals who present with ED, in that they have often accumulated a wealth of ‘nutritional knowledge’ from a variety of sources and sometimes over many years. Challenging these dietary beliefs (that have often initially proved beneficial, in that they achieved weight loss in the short term), and adding more dietary advice, can be very difficult. This can be further compounded by the large claims and often glamorised promises of many popular and highly-marketed/publicised weight-loss diets, which are promoted by non-HCPC registered individuals/groups. Individuals can often fail to see that the diets were indeed the problem (ie, following a restricted diet, physiologically and psychologically, significantly increases the risk of binge eating) and instead, blame themselves for not adhering to the diet that previously proved successful. This raises the question: is enough being done to protect the public against the potential risks of ‘weight-loss/ health diets’ promoted by non-HCPC registered individuals? It also gives rise to further questions: Whose responsibility is it to provide this protection, and what is the role of the dietitian in protecting the public? Could we be doing more? As a profession and as individuals, should we be challenging non-evidence-based and potentially dangerous practices? Can we do more to increase public awareness of the value of seeking dietary advice from a dietitian?

EVENTS & COURSES

For more events and courses visit NHD.mag.com

This highlights the need for clearer guidance on the risks associated with promoting thin as healthy and beautiful and the negative body image and increased dieting behaviour (and, thus, an increased risk of developing an ED) that this can cause. Is it possible to legally prevent inadequately qualified individuals and groups from providing and profiting from non-evidencebased and unsuitable dietary advice and unrealistic expectations/goals? Can they indeed be held accountable for the physical and mental health problems that their advice can contribute to? CONCLUSION

ED are complex with many contributing factors. The idealisation of thinness and the dietary advice available to promote weight loss to achieve this, are recognised risk factors in the development and maintenance of ED. It is also recognised that there is a need to protect the public from poor/unsuitable nutritional and dietary advice/ recommendations and, thus, the title of dietitian can only be used by those regulated by the HCPC. However, there is a plethora of non-HCPC registered individuals and groups who provide and profit from nutritional and dietary advice. It is difficult to identify if/how the public can be protected against unregulated advice and this, therefore, gives rise to the suggestion that clearer guidance and enforcement procedures are needed. It also highlights the need to further explore the potential role of the dietitian and the dietetic profession, in raising awareness of the risks and challenging unsuitable practices.

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PAEDIATRIC

FOLLOW-ON FORMULA Follow-on formula milk (FOFM) is marketed to infants aged 6-12 months who are receiving complementary foods. Although there are some subtle nutritional differences between first infant and FOFM, there is no real benefit for the majority of infants in switching from a first infant formula to a FOFM once complementary feeding has begun. The legal definition of FOFM from the Department of Health is: ‘Foodstuffs intended for particular nutritional use by inference when appropriate complementary feeding is introduced and constituting the principal liquid element in a progressively diversified diet of such infants.’1 The main difference between first infant formula milk and FOFM is the iron content: FOFM has more iron than first infant formula.2 There are also other subtle differences in vitamin D, calcium and carbohydrate content (see Table 1). These additions are intended to address the fact that UK infants aged over six months are often lacking in iron and vitamin D.3 Prior to 2014, FOFM had a higher protein content, but this has since been decreased due to concerns about the association of high protein intakes in infancy with increasing risk of obesity.4 This was as a result of guidance from the European Food Safety Authority (EFSA), recommending that the protein content of FOFM should be lower than it was previously.5 BREASTFEEDING

The World Health Organisation (WHO) recommends breastfeeding for the first six months of life in order to achieve optimal growth, development and health.6 The WHO also states that even though FOFM is not necessary and is unsuitable when used as a breast milk replacement, it is marketed in a way that may cause confusion and have a negative impact on breastfeeding.6

A number of studies strongly suggest a direct correlation between marketing strategies for FOFM and perception and subsequent use of these products as breast-milk substitutes. In many instances, the packaging, branding and labelling of FOFM closely resemble that of infant formula. This leads to confusion as to the purpose of the product, ie, a perception that FOFM is a breast-milk substitute. This may result in its early introduction, thereby undermining exclusive breastfeeding up to six months of age and sustained breastfeeding for up to two years or beyond.8,9,10,11 This is very concerning because, in the UK, we have one of the lowest breastfeeding rates in the world, with only 1% of babies being exclusively breastfed to six months of age, compared with 36% globally.7 In the 2010 UK infant feeding survey, 81% of mothers initiated breastfeeding soon after birth, 17% were still exclusively breastfeeding at three months and 12% at four months of age.6 The majority of mothers in the UK who discontinue breastfeeding report that they would have liked to breastfeed for longer: 90% of mothers interviewed who stopped by six weeks and 63% who stopped when their babies were six to eight months of age.12 A recent study13 in Italy about FOFM advertisements and their perception by pregnant women, found that participants were unable to define what the advertised products were, due to the ambiguity of the age of the infants pictured in the advertisements and not knowing that the number ‘2’ represented FOFM, as well as the prominence of the brand name. The

Paula Hallam RD, PG Cert (Paed Diet) Specialist Paediatric Dietitian Paula is a Specialist Paediatric Dietitian and owner of Tiny Tots Nutrition Ltd. She helps families of babies and children with many nutritional concerns, such as fussy eating, iron deficiency anaemia, constipation, growth faltering and food allergies. She also facilitates weaning workshops for new mums. www.tinytots nutrition.co.uk

REFERENCES Please visit the Subscriber zone at NHDmag.com

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PAEDIATRIC Table 1: FOFMs available in the UK, compared with human breast milk and first infant formula Brand per 100ml

Energy (kcal)

Protein (g)

CHO (g)

Fat (g)

Iron (mg)

Vitamin D (ug)

Calcium (mg)

Cost (£/kg)

Human mature breast milk

1.3

7.2

4.1

0.07

66-67

1.2-1.5

7.3-7.5

3.2-3.6

0.30.70

0.9-1.7

39-55

£9.38£20

Cow & Gate 2

1.4

8.6

3.0

1.0

1.5

£10

Aptamil 2

1.4

8.5

3.1

1.1

1.5

£13.57

SMA Pro 2

1.3

7.9

3.2

1.0

1.2

£12.50

HiPP organic 2

1.5

7.8

3.5

1.0

1.2

£11.88

SMA little steps 2

1.5

8.0

3.2

0.81

1.7

£9.38

Aptamil Profutura 2

1.4

8.8

2.9

1.0

1.3

£16.90

SMA Advanced 2

1.3

7.8

3.5

0.7

0.9

£20

SMA organic 2

1.35

8.1

3.2

0.87

1.7

£15

First infant formula

Table 2: Iron requirements in the first year of life* Age (months)

Iron (mg/day)

0-3

1.7

4-6

4.3

7-9

7.8

10-12

7.8

* Great Ormond Street Hospital nutritional requirements for children in health and disease, 2014

study concluded that advertisements for FOFM are perceived by pregnant women as promoting infant formula.13 The marketing of FOFM makes it confusing for parents, as adverts can make vulnerable new parents feel pressurised into switching from a first infant formula to a FOFM, or from breast milk to a FOFM. Many believe that FOFMs were created to circumvent infant formula regulations related to advertising,2 as the advertising of FOFM is permitted in the UK. REGULATIONS AND RECOMMENDATIONS

In the UK The UK Law prohibits the advertising and promotion of infant formula only (marketed for use from birth). FOFM (marketed for use from six months of age) and milks for older babies can be advertised and promoted; BUT this must not cross-promote infant formula through similar branding, or by it not being obvious that the product is for older babies. 22

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International Code and Resolutions The International Code is a unique and indispensable tool to protect and promote breastfeeding and to ensure that marketing of breastmilk substitutes, feeding bottles and teats is appropriate. The International Code was prepared by the WHO and UNICEF after a process of widespread consultation with governments, the infant feeding industry, professional associations and NGOs. It was adopted by the World Health Assembly in 1981. The Code and Resolutions prohibit all advertising and other forms of promotion of breast milk substitutes, feeding bottles and teats. The ban on promotion covers infant formula, FOFM and milks for older babies (up to 36 months). There is no restriction on products being sold, as long as they comply with labelling and composition requirements. Companies may provide scientific and factual information to health workers. Health workers are responsible for supporting parents.

PAEDIATRIC

As healthcare professionals, it is our role to support mums to breastfeed for as long as they would like to and where formulas are used, provide the advice and information as appropriate.

More information can be found via the International Baby Food Action Network (IBFAN) website: www.ibfan.org/what-is-theinternational-code/. Is FOFM recommended? No. The WHO, the UK Department of Health and NHS all state that the use of FOFM is unnecessary and unsuitable as a breast milk substitute and that infants six months and older, who are not being breastfed, are advised to continue on a first infant formula milk until 12 months of age. FOFM should not be given to babies under six months of age and care should be taken to avoid making a mistake, as the labels on FOFM can look very similar to those on first infant formula milk.6 NUTRITIONAL COMPOSITION

The main difference between first infant formula milk and FOFM, as already stated, is the increased iron content. There are also other subtle nutritional differences (see Table 1). Iron The iron content of FOFM is higher than that of first infant formula, although there is considerable variation and, in some cases, the iron content in first infant formula and in FOFM is the same (in different brands). This higher iron content is marketed as a possible advantage to switching to FOFM from a first

infant formula. Iron deficiency anaemia is one of the most common nutrient deficiencies in the world in infants and young children.3 One in eight children in the UK between the ages of 1828 months are reported as having iron deficiency anaemia (low haemoglobin), whilst many more could be iron deficient (low serum ferritin â&#x20AC;&#x201C; the iron storage marker).3,14 Babies born full term and of normal birth weight, are born with sufficient iron stores to last for around six months of age. Maternal iron status during pregnancy and delayed cord clamping have both been shown to have an influence on the iron status of the infant throughout the first year of life. It is for this reason that both ESPGHAN and NICE recommend that delayed cord clamping should be considered for all newborns.15 Formula companies have utilised the fact that iron requirements of infants increase from six to seven months of age due to decreased endogenous iron stores, and so market FOFM as being beneficial for infants from six months of age. A study from 201315 showed that FOFM was positively associated with iron status in late infancy, whilst cowâ&#x20AC;&#x2122;s milk was negatively associated. However, breastfeeding was not shown to impact negatively on iron status. In another study17 it was found that FOFM improved iron stores of infants and toddlers, but it was not shown to be beneficial for development or growth. The evidence shows www.NHDmag.com August/September 2019 - Issue 147

PAEDIATRIC that FOFM may be beneficial in improving iron stores of infants and toddlers, but it is not clear what benefit this will serve alongside an ironrich weaning diet. Globally, it is agreed that FOFM serves no nutritional purpose and WHO clearly states that FOFM is unnecessary.6 First Steps Nutrition Trust2 explain in their Infant milks in the UK report that there is also some evidence that excessive iron intakes may result in a reduced uptake of other trace metals, including copper,17 and that high iron intakes in iron-replete infants and toddlers may actually have an adverse effect on growth and development. A recent large study from Chile looking at the impact of ironfortified formula in infants aged 6-12 months on a range of cognitive and learning outcomes at 10 years of age, showed that iron-replete infants given iron-fortified formula did significantly less well in terms of long-term development than similar infants given low-iron formula, or irondeficient infants given high-iron formula.19 Calcium The calcium content of FOFM is higher than that of first infant formula milks and breast milk (see Table 1). In the UK, infants are recommended to have 525mg calcium per day until 12 months of age, after which calcium requirements drop to 350mg calcium per day for one to three-year olds. Calcium requirements can easily be met by a combination of breast milk/first infant formula and a small amount of yoghurt, cheese, or cow’s milk used within foods (see example below). Additional calcium from FOFM is unnecessary. Cow’s milk should not be given as a main drink until at least 12 months of age. Example: • 600ml breast milk (estimate of intake) = approx 200mg calcium OR 600ml first infant formula = 234-330mg calcium (depending on brand of formula) • 15g cheese = 120mg calcium • 50g yoghurt (small pot) = 100mg calcium • 100ml cow’s milk (within foods or over cereal) = 120mg calcium Vitamin D Another nutritional feature of FOFM is a slightly higher vitamin D content compared to (most) 24

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first infant formulas. This fact is often used in the marketing campaigns of the FOFM companies to promote their formula. However, in the UK, vitamin D supplements of 8.5-10 micrograms are recommended for all breastfed infants and for formula-fed infants when formula intake is less than 500ml per day. First infant formula milks contain sufficient amounts of vitamin D when an infant is drinking more than 500ml per 24 hours. THE COST OF FOFM

There are wide variations in the cost of FOFM, ranging from £9.38 to £20 per kg of powder, depending on the brand of formula. As an example, if a seven-month-old baby drinks 600ml of FOFM per day, this would cost a family £24.50 to £52.50 per month, depending on which brand of FOFM was used. The All-Party Parliamentary Group on Infant Feeding and Inequalities and First Steps Nutrition Trust recently published a report20 on an inquiry into the financial impact of infant formula on family budgets in the UK. The inquiry found that the high cost of infant formula is reported to be having a seriously negative impact on a number of families in the UK, and that this may lead to unsafe feeding practices, as well as the possibility of parents limiting their own food intake, or that of other children, in order to make ends meet.20 CONCLUSION

FOFM contains more iron than first infant formula, as well as having other subtle nutritional differences. However, there is no clear evidence for its use in infants from six months of age, as long as iron-rich complementary foods are introduced from this age. There are few advertising restrictions on FOFM in the UK and this increases the risk that infants may be inappropriately switched to a FOFM. As healthcare professionals, it is our role to support mums to breastfeed for as long as they would like to and where formulas are used, provide the advice and information as appropriate. I personally would like to see the UK adopt the ‘International code and resolutions’ from IBFAN, so that the advertising of FOFM in the UK is prohibited by law.

CLINICAL

PRE-OPERATIVE NUTRITION Any form of surgical procedure causes the body physiological stress, the extent to which depends on the severity of the surgery.1 Surgical procedures can have a profound impact on a patient’s nutritional status and this article sheds light on the importance of adequate nutrition in the lead up to surgery. Most surgical procedures do not require a specific diet to be followed prior to surgery other than a well-balanced and healthy diet. We should all be aiming to eat more fruit and vegetables, wholegrains, and oily fish,2 keeping the government Eatwell Guide in mind (see Figure 1). In the UK, it is recommended that we consume two portions of fish a week, with at least one portion (140g) from oily fish.4 We should also choose lean meats and low-fat dairy, as well as heart healthy fats such as olive oil and rapeseed oil. Saturated fat, alcohol and caffeine should be limited to recommended amounts. Most younger and middle-aged people in the UK consume above the recommended daily amount of protein;2 however, people who follow a vegan or vegetarian diet should make sure they are consuming adequate amounts of protein from plant-based sources such as lentils, chickpeas, peanuts, tofu, edamame beans. Elderly people and people with chronic illnesses do not always consume enough protein in their diet, which can lead to muscle loss and sarcopenia, so optimising protein intake prior to surgery is important.5 ESPEN guidelines suggest that healthy older people should have at least 1.0-1.2g of protein per kilogram of bodyweight per day, and those with acute or chronic illnesses may require as much as 1.5g of protein per kilogram of bodyweight per day.6 It’s important that patients are adequately hydrated in the lead up to their surgery to avoid dehydration, as this can cause post-operative complications.7

SPECIFIC DIETARY REQUIREMENTS

In some cases, specific dietary requirements apply. For example, before bariatric surgery, a supervised weightmanagement program is recommended. This involves patients following a verylow-calorie diet (sometimes referred to as a liver-shrinking diet) for several weeks. This dietary approach has been associated with a 10% weight loss and a 15-20% reduction in liver volume, making the surgery easier to perform.8 In addition, patients with diabetes require an individualised approach. The Joint British Diabetes Societies for Inpatient Care have released a specific set of recommendations for the management of adults with diabetes undergoing surgery and elective procedures. During the pre-operative stage, they recommend that clinicians should:9 • assess adequacy of glycaemic control against the urgency of procedure; • consider a referral to the diabetes specialist team; • identify other comorbidities with referral to appropriate teams for optimal management where necessary; • ensure availability of usual insulin and medications; • give the patient clear written instructions for any changes to their medication as well as fasting guidelines prior to admission; • ensure patients with diabetes are not placed on an evening list as this avoids prolonged starvation times.

Harriet Smith RD Freelance Dietitian and Health Writer Harriet is Founder of Surrey Dietitian providing private dietetic consultations and consultancy services, offering evidence-based nutritional advice, backed up by the latest research on food, health and disease. Harriet has written for national, consumer and industry media. www.surrey dietitian.co.uk @SurreyDietitian

REFERENCES Please visit the Subscriber zone at NHDmag.com

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Getting Nan back to her old tricks again!

is a powdered, neutral-tasting carbohydrate loading drink mix for the pre-operative dietary management of patients undergoing surgery. has been shown An Enhanced Recovery Programme including the use of to significantly reduce post-operative hospital stay with a return towards earlier gut 1 function when compared with fasting or supplementary water. Helping patients get back to doing the things that they enjoy sooner.

Preload™ is a Food for Special Medical Purposes and must be used under strict medical supervision. 1. Noblett S, Watson D, Huong H, Davidson B, Hainsworth P, Horgan A (2006) Pre-operative oral carbohydrate loading in colorectal surgery: A randomized controlled trial. Colorectal Disease: 8, 563-569.

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CLINICAL Figure 1: Government Eatwell Guide3

Eatwell Guide

Check the label on packaged foods

Use the Eatwell Guide to help you get a balance of healthier and more sustainable food. It shows how much of what you eat overall should come from each food group.

Each serving (150g) contains Energy 1046kJ 250kcal

13%

Fat

Saturates Sugars

3.0g 1.3g LOW

LOW

Salt

34g 0.9g HIGH

38% 15%

of an adult’s reference intake Typical values (as sold) per 100g: 697kJ/ 167kcal

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Eat at leas t5

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Whilst there are no general clinical guidelines on vitamin and mineral supplementation prior to surgery, some surgeons may give specific recommendations. For example, pre-operative oral iron supplementation is sometimes used in patients undergoing colorectal10 or joint surgery11 to reduce transfusion requirements. The UK government recommends that people over the age of one should take a daily 10mcg vitamin D supplement,12 particularly during autumn and winter, due to the reduced exposure to sunlight (the main source of vitamin D in the UK). Vitamin D is an important component in musculoskeletal development and deficiency is thought to have widespread consequences for bone healing.13 It is important that patients inform their surgeon of any supplements or herbal remedies they are taking prior to their operation, as these may interact with certain medications. Several potential adverse interactions between commonly used herbal supplements and analgesic drugs are listed below.14

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Per day Source: Public Health England in association with the Welsh Government, Food Standards Scotland and the Food Standards Agency in Northern Ireland

NUTRITIONAL SUPPLEMENTS

Limit fruit juice and/or smoothies to a total of 150ml a day.

Rice

Lentils

Eat less often and in small amounts

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• Non-steroidal anti-inflammatory drugs (NSAIDs) can interact with certain herbal supplements and increase the risk of bleeding. These include: - those with antiplatelet activity (ginkgo, garlic, ginger, bilberry, Dong Quai, feverfew, ginseng, turmeric, meadowsweet and willow); - those containing coumarin (chamomile, motherwort, horse chestnut, fenugreek and red clover); - tamarind; - opioid analgesics can interact with sedative herbal supplements (valerian, kava and chamomile), which can increase central nervous system depression. • Paracetamol can interact with some of the herbal supplements mentioned above (and gingko), which increases the risk of bleeding. • Paracetamol can also react with certain herbal supplements and increase the risk of hepa-totoxicity and nephrotoxicity. These include: www.NHDmag.com August/September 2019 - Issue 147

CLINICAL - echinacea and kava; - herbs containing salicylate (willow, meadowsweet). OPTIMISING NUTRITIONAL STATUS

Studies have shown that being malnourished prior to surgery is associated with a significantly higher risk of post-operative complications, including surgical site infection.15 A person is classified as malnourished if they meet a set of criteria that includes a low BMI (<20kg/ m2), unintentional weight loss (5-10% of their usual body weight) over the past three to six months and being acutely unwell with little or no nutritional intake for five or more days.16 Guidelines recommend delaying elective surgery in patients with malnutrition until their nutritional status has improved.17 Although obesity is no longer considered a risk factor for post-operative complications,18 it can increase the operating time.19 Nutritional screening is recommended in NICE guidelines for all inpatient hospital admissions in the UK and patients should be reviewed weekly thereafter. Patients should have their height and weight measured during their pre-op assessment and at regular intervals after their operation.20 Unfortunately, research suggests that pre-operative nutritional status of surgical patients is poorly conducted, even though pre-operative weight loss is widely recognised as a post-operative cause of morbidity and mortality.17 FASTING

Prior to surgery, patients are required to fast (usually overnight) to reduce their risk of complications during the general anaesthetic.21 The rationale behind pre-operative fasting is to reduce the volume and acidity of gastric contents, which, in turn, reduces the risk or regurgitation and aspiration of gastric contents into the lungs during surgery. However, there is lack of evidence to support this rationale.17 Most hospitals have their own fasting policies and each hospital will inform their patient of the fasting guidelines prior to their operation. The Royal College of Nursing guidelines for pre-operative fasting in the UK permit low-risk patients to have clear fluids 28

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for up to two hours before surgery and milky drinks and solid foods up to six hours prior to surgery.17 CARBOHYDRATE LOADING

In recent years, carbohydrate loading has received widespread attention. Consuming carbohydrate-containing drinks up to two hours before surgery has been found to be an effective way to attenuate insulin resistance, minimise protein losses, reduce hospital stays and improve patient comfort without adversely affecting gastric emptying.22 Thus, carbohydrate loading has been included in many fast-track surgery protocols; however, components of these protocols have not been subject to critical analysis.17 A 2014 Cochrane review evaluated the findings from 27 randomised controlled trials, which included almost 2000 participants. They found that giving patients at least 45g carbohydrate drinks within four hours of surgery or anaesthesia start time, resulted in patients going home half a day earlier than those receiving a placebo drink following traditional fasting guidelines. However, the carbohydrate drinks had no effect on reducing complication rates. The authors also concluded that the quality of evidence varied, and over half of the studies were at a high risk of bias.23 CONCLUSION

Ensuring that a patient is well-nourished and hydrated prior to surgery is crucial for optimising recovery and clinical outcomes. Dietitians play an important role in ensuring that hospital trusts are implementing appropriate nutritional screening guidelines for all inpatients so that malnutrition can be identified and addressed early on. Common surgical procedures do not require specific pre-operative dietary approaches, other than eating a healthy balanced diet and following hospital fasting guidelines. However, patients undergoing specific surgeries, or those with certain medical conditions, or medications/ supplements, may require an individualised dietary approach, which may require support from dietitians and other healthcare professionals.

PRETEEN OBESITY: THE PARENT’S ROLE

NUTRITION MANAGEMENT

In this article, Farihah delves into the specific realms of preteen or childhood obesity and what role a parent might play in this. In developed countries, such as the United Kingdom, some of the largest public health problems stem from rising prevalence of non-communicable diseases, obesity being one. Childhood obesity in particular has increased steadily throughout the last decade and currently sits at a 40-year high globally,1 and although figures have almost plateaued in the last few years,2 prevalence has not diminished. It is well-elucidated now, that obesity and overweight are caused and exacerbated by multiple factors. Although it is easy to put the blame on one single thing, current research clearly demonstrates that overweight and obesity are, to various extents, caused by: • varying genetic dispositions; • metabolic conditions; • warped perceptions of portion size leading to greater consumption; • increase in consumption of high calorie food products and a decrease in consumption of fresh produce; • decreased physical activity due to an increase in the use of digital technology and a move away from labour-driven occupation and leisure; • appetite control mechanisms; • a variety of cofounding factors, including existing health conditions and lifestyle situations. Obesity and overweight lead to a heightened risk of comorbidities, including, but not limited to, cardiovascular disease, Type 2 diabetes mellitus, many cancers, gallstones and sleep apnoea. The first case of noninsulin dependent diabetes mellitus was recorded in a child in 20023 and 715 young people under the age of 25 were diagnosed with Type 2 diabetes in the audit year, according to the Royal

College of Paediatrics and Child Health National Paediatric Diabetes Audit 2016-17. This was an increase of 77 from the previous audit year.4 Clearly, there is a huge public health issue on our hands. However, children have limited agency in managing their health and symptoms, so in what capacity could parents be facilitating an obesogenic environment, or is it unfair to point the blame at parents alone? THE PICTURE IN ENGLAND

The report from Public Health England (PHE), Patterns and Trends in Child Obesity (updated Feb 2019),5 profiles childhood obesity via the National Measurement Programme.17 Its findings illustrate that 1 in 10 Reception children (aged 4-5) is obese and 1 in 5 children in Year 6 (aged 10-11) is obese. See Figure 1. The Health Survey for England 20176 summarises that 30% of children aged 2-15 were overweight or obese, including 17% who were obese. Interestingly, the same survey revealed telling data about parents’ perception of their children’s weight. The report shows that parents of overweight and obese parents often thought that their child was “the right weight”. Around half of parents of obese children said that their child “seemed about the right weight”.6 Does this perception lead to delayed or insufficient intervention?

Farihah Choudhury Community Engagement Worker, Healthwatch Southampton Farihah is a prospective Master’s student interested in Public Health Nutrition, in particular lifestyle disease, including obesity as a product of changing food environments, gut health, food security and food waste, food poverty and food marketing and literacy.

REFERENCES Please visit the Subscriber zone at NHDmag.com

PARENTAL CONTROL, INFLUENCE AND ATTITUDES

A foetus gets used to the taste of the maternal diet during pregnancy and infants who are breastfed experience the maternal diet further through breast milk. This facilitative experience provides a ‘flavour bridge’ to infants, which can influence acceptance of certain foods later in life.7 www.NHDmag.com August/September 2019 - Issue 147

NUTRITION MANAGEMENT Figure 1: BMI status of children by age, National Child Measurement Programme 2017/18, Public Health England.5

The former two types of feeding are associated with eating in the absence of hunger.9 Children generally eat what their parents eat: if an adult eats five portions of fruit and veg a day, it is likely that their children will do the same. Similarly, if an adult eats a burger and chips for dinner every night, then in most instances (and there are, of course, practical reasons for this), the children will have the same meal. Several studies have reflected that parental food behaviour does reflect on children,9 such as intake of high energy fluids, snacks and take-outs, as well as finding a correlation between parental internal motivation and body dissatisfaction and that of their children.10 In regards to controlling over eating, restrictive diets early in life may result in disordered eating habits when food autonomy starts to develop, not only in the teen years, but throughout primary education. Furthermore, exposure to adults who have disordered relationships with 30

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food may intensify poor relationships with food in children, which can follow into adulthood.9 Hence, it can be argued that a parent’s role is to provide a non-restrictive and healthy varied food environment for young children during weaning and beyond, to the best of their ability, which can influence eating and dieting behaviours in early childhood, as well as later in life.9 In a similar vein, encouraging body confidence and positivity amongst children early on is instrumental for children to feel empowered to make the choices that are right for them throughout their lifetime. Shaming children for their weight often leads to a cascade of issues, including continuing poor relationships with food, often a contributing factor for rapid weight gain or weight loss. On the other hand, as aforementioned, parents of overweight or obese children often perceive their children to be at a healthy weight. This is not an isolated observation – this warped perception has been observed in several studies.11 Moreover, there is a strong association between childhood trauma and disordered or over-eating. Generally, happier children with protection from adversity and trauma in early years are less likely to develop eating disorders or behaviours that may lead to obesity, ie, overeating/emotional eating, as well as eating disorders such as bulimia and anorexia nervosa. Obese early years’ children are more likely to have behavioural issues and obese children are more likely to be burdened by mental and psychological issues into adulthood.12

Focusing on the psychological aspects of obesity, influencing and promoting children to have a healthy relationship with food early on increases the likelihood that children will develop good eating habits throughout childhood and later in life.8 Four common feeding styles have been observed by Wardle et al9 that contribute to the development of childhood obesity: • instrumental feeding • emotional feeding • control over eating • prompting/encouragement to eat

NUTRITION MANAGEMENT Despite the generally clear and widely perceived view that parents are responsible for weight management of their children, there are inconsistencies in this body of research, where some associations are much stronger than others. More long-term clinical studies may need to be conducted in order to be able to confidently declare a relationship between parental influence on food consumption and childhood obesity. THE HEREDITARY ROLE OF THE PARENT

Some individuals are genetically predisposed to retaining excess adipose tissue. Parents who have this predisposition play an inevitable role in obesity in their biological children, although the likelihood of becoming obese in childhood could be mitigated in various ways, for example, being birthed naturally (ie, not via caesarean section), being breastfed, or having a healthy varied diet during early childhood.13 However, it is an inescapable reality that some individuals are simply more likely to gain weight (and keep it) than others, regardless of lifestyle and dietary choices. Furthermore, individuals belonging to certain ethnic groups are more susceptible to overweight and obesity than others. However, this can be due to a combination of factors, including social deprivation and biological factors. In girls, obesity prevalence is highest among those in black African, black Caribbean and other black ethnic groups. In boys, obesity prevalence is highest in black African and black other and Pakistani ethic groups. The lowest obesity prevalence is found in Chinese and white/Asian mixed backgrounds.5 Linked in part to ethnic groups, socioeconomic factors are strongly linked to obesity prevalence.5,14,15 Deprivation indices against obesity prevalence consistently show that affluent areas have less individuals with overweight and obesity than less affluent areas. In Year 6 children, 26.3% of those in the most deprived areas were found to be obese, compared to only 11.4% of children in the least deprived areas.5 PHYSICAL ACTIVITY

We know all too well that we live in a technological age, where both occupational and leisure activities are increasingly technology-based, resulting in physical activity falling for all age groups and average Physical Activity Levels (PAL) being lower than is recommended. Children are able to access a

myriad of educational and entertainment resources from smartphones and tablets, which sometimes comes with its benefits, but also means that outdoor play is scarcer and thus physical activity is reduced. Arguably, it is the parents’ role to encourage active play and enrol children into sports classes and the like, whether via after-school clubs or activity sessions outside of the educational sphere. Early exposure to active play and team sports are linked to various physical and mental benefits later in life, as well as for maintaining a healthy weight. Undoubtedly, social deprivation acts as a barrier to parents who often have less time and/ or money to spend on taking children to sports classes. Structural and institutional social change might allow for increased provision for free afterschool sports clubs and free access to active leisure facilities, or concessionary and reduced prices. Since 2009, the PHE campaign Change4Life18 has offered free, fun and informal guides to being active for children and families. It is the first public health campaign in the country designed to specifically tackle the rising obesity epidemic. Over the summer holiday period, it is possible to sign up to a fun scheme to ensure physical activity takes place in and around the home. Change4Life has proven to be a huge success, exceeding all of its first year targets, including the reach of 99% of targeted families, and receiving 1.9 million responses.16 In Change4Life’s 10th year of championing physical activity in children and families, has the campaign done enough to tackle childhood obesity? SUMMARY

It is clear that we live in an obesogenic environment that affects children’s ability to maintain healthy lifestyles through little fault of their own. Although existing research has established a causal relationship between parents’ control and influence of children’s diets and childhood obesity, more specific research needs to be conducted in this area over a longer timeframe. Despite this, there are clear links between parental BMI, parental food intake and dietary preferences and their effect on childhood overweight factors. It is encouraging that the worryingly rapid rise of obesity has, to an extent, halted in the UK. Nevertheless, more intervention is required if we are to make a significant dent in the obese young person population. www.NHDmag.com August/September 2019 - Issue 147

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EGGS: FRIEND OR FOE?

COMPETITION WINNER

This review aims to explore the nutritional composition of eggs, as well as examine the wide range of health benefits associated with including eggs as part of a balanced diet. “An egg a day is okay…” So, will it be poached, fried or scrambled? Boiled, soft or hard? With smashed avocado, smoked salmon, or the old reliable Marmite? Will you have the whole egg, or just the whites? Or should we be eating eggs at all? For such a seemingly unassuming food, eggs have stirred up much debate and even now there are still many misconceptions regarding their place in a healthy diet. Around the world, habitual egg consumption varies hugely, with intakes as high as 358 eggs per capita per year in Mexico and as low as 36 per year in certain African countries.1 In the UK, the NHS guidelines state that, ‘There is no recommended limit on how many eggs people should eat’3 and eggs are included in the Eatwell Guide,18 alongside meat, fish, beans and nuts. Two eggs are considered as one serving.19 In Ireland, Safefood does not include specific recommendations for eggs for the healthy general public.2 There are of course certain subgroups of the public who will need to be mindful of egg consumption, eg, those with metabolic disorders, including hypercholesterolemia, or those with an egg allergy.1 However, the majority of people can safely consume eggs on a regular basis. WHY THE CONFUSION?

In the past, eggs have gained a bad reputation due to their high cholesterol content: 400mg/100g, or approximately 213mg per large egg/186mg per medium egg.1,4,5

Laura Kaar Student, Trinity College Dublin and Technological University of Dublin

In 1986, the American Heart Association brought out new guidelines recommending that people consume no more than three whole eggs per week and less than 300mg of cholesterol a day, in an attempt to prevent heart disease.4 These recommendations resulted in a sharp decline in egg consumption, as people began to limit their intake.4 Thankfully, much more research has been carried out since then and such recommendations have been removed from the majority of national dietary recommendations. In 1999, a large long-term population study found no difference in heart disease risk between those consuming one egg per day compared with those having one egg per week, and many studies, including epidemiological studies and meta-analyses, have reported similar findings.4.6 This, in part, may be due to poor absorption of cholesterol in eggs, since consumption of eggs is not associated with an increase in total plasma cholesterol concentration.7 The antioxidants found in eggs may also play a protective role with respect to heart disease, as discussed further below.6 It is also important to remember that the vast majority of an individual’s serum cholesterol comes from endogenous cholesterol biosynthesis (up to 75%), with dietary cholesterol responsible for the remainder.5

Having just finished her final year in Dietetics, Laura is very much looking forward to starting work as soon as possible. She previously completed a degree in biochemistry and is also a qualified horse-riding instructor.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Look for the British Lion mark when buying eggs to ensure the highest standards of food safety. More info at: egginfo.co.uk

www.NHDmag.com August/September 2019 - Issue 147

Laura's winning article, in our NHD/British Lion eggs competition, was judged by Dr Carrie Ruxton and NHD Editor Emma Coates. Our thanks to everyone who took the time to enter.

FAT: THE GOOD, THE BAD OR THE UGLY?

Water makes up the majority of an egg (76%), while fats and protein account for 9.5% and 12.6% respectively.1 In total, one medium egg will provide approximately 78kcal, 5.3g of fat and 6.29g of protein.5 Despite what was previously thought, in 2017, Lopez-Sobaler et al went as far as describing the fatty acid profile of eggs as ‘favourable’ with respect to heart disease.8 In comparison with other animal food sources, eggs have a high ratio of unsaturated fat to saturated fat and are a useful source of many essential fatty acids, including linoleic acid.1 Of the 5.3g of fat found in one medium egg, approximately 1.6g is saturated, 2g is unsaturated and 0.7g is polyunsaturated.5 A systematic review published in 2017, found that replacing saturated fat in the diet with polyunsaturated and monounsaturated fats was protective with respect to coronary heart disease.9 The daily reference intake for adults is 70g total fat and 20g saturated fat,20 and so, a serving of two medium eggs would contribute approximately 15% of total fat and 16% of saturated fat for an adult.10 This serving would also provide approximately 150kcal and 13g of protein, equating to 7.5% of the daily energy requirements for an adult female requiring approximately 2000kcal per day. Finally, eggs contain less than 1% carbohydrates and do not provide any fibre.1 THE ORIGINAL PROTEIN BALLS?

The recent rise in popularity in processed (and often rather expensive) protein balls would have been hard to miss for anyone who has set foot in a supermarket or health food shop in the past few years. Not to mention the abundance of 'bliss' balls, energy balls and, 34

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of course, protein bars now available at every checkout. However, when we look at what the humble egg can deliver in terms of macro- and micronutrients, we may be better off holding onto our well-earned pennies and popping a hard-boiled egg or two into a lunch box instead. Eggs are well known as an accessible economical source of high biological value protein.11 At present, six medium sized freerange eggs from a national retailer costs £1.59 (0.27p per egg).12 That is excellent value for a food product that has been described as being one of the ‘best sources of high quality protein only inferior to breast milk’.5 The protein found in eggs is also a valuable source of the essential amino acid leucine, which is proven to have a role in stimulating muscle protein synthesis.11 The protein found in an egg is split between the white and the yolk, with the yolk also housing the vast majority of the fatty acids and micronutrients.1 Contrary to the beliefs of bodybuilders who avoid the yolk to save a tiny amount of fat and calories, consumption of whole eggs appears to be more beneficial in stimulating muscle protein synthesis than egg whites alone.13 This is why it is better to eat the whole egg in order to reap the full health benefits. THE WHOLE EGG

As with any food, it is important to consider the overall picture and not focus solely on the potential adverse or beneficial impact of one or two nutrients. Beyond calories and macronutrients, eggs provide a rich source of micronutrients and bioactive compounds. The main role of the yolk is nutritive; however, it doesn’t simply provide essential nutrients, but contains formats that are readily available

COMPETITION WINNER and easily metabolised.14 Examples include the minerals iron and zinc, which are important for normal cognitive and immune function. Eggs are known to be a valuable source of choline, which has many essential roles, particularly in infant development and in the eye, since it is a precursor for the phospholipids required for cell growth, division and signalling.14 Higher dietary intakes of choline have been associated with lower circulating markers of inflammation, including C reactive protein (CRP) and so may be protective against inflammatory process and related diseases.15 Eggs also provide a rich source of antioxidants including vitamins, minerals and bioactive compounds.1 Examples include the carotenoids, lutein and zeaxanthin, which are highly bioavailable in egg yolk, even more so than in supplements or plant sources.11 Interestingly, research has shown that the levels of both of these carotenoids can be increased by as much a tenfold by adding marigold to hens’ diets.4 This could be very beneficial, as the antioxidants present in eggs may inhibit oxidative damage and potentially protect against degenerative processes, including those characteristic of cardiovascular disease.5 Eggs are one of the few foods naturally containing vitamin D, with approximately 41IU (1.02mcg) per egg, most of which is in the yolk.11 A serving of two eggs would, therefore, provide just over 20% of the 400IU (10mcg) RNI as recommended by SACN.16 A 2016 study

involving an animal model of diabetes, found whole eggs to be more beneficial for maintenance of vitamin D levels than supplementation.17 Reaching and maintaining recommended vitamin D levels is notoriously difficult for many reasons. This is partly due to a lack of foods that naturally contain this essential nutrient. However, regularly including whole eggs in the diet may be an effective way to help people achieve requirements, alongside the relevant recommended supplementation. CONCLUSION

This article has briefly touched on a range of the benefits of eggs documented to date. It is clear that despite previously held beliefs in relation to heart disease, for the general healthy population, eggs are now widely considered a useful source of high-quality protein and healthy fats. Based on the current evidence available, the inclusion of eggs in a healthy balanced diet is not associated with an increased cardiovascular disease risk. Eggs will provide a rich source of many essential micronutrients, including vitamin D, choline and iron. In the future, even more benefits of the bioactive compounds in eggs, in particular certain egg proteins, may be found, as the role of many of these compounds has yet to be identified.1 When considering the wide range of benefits associated with egg consumption, it is clear that eggs have the potential to play an important role in any healthy balanced diet, whatever way people choose to eat them.

Obituary IN MEMORY OF DR BRIONY JANE THOMAS PhD RD 28th June 1950 – 28th May 2019 Family, friends and colleagues came together in June to say goodbye to Briony Thomas, Editor of The Manual of Dietetic Practice. Briony devoted 23 years (1984-2007) to this book, which has become known and loved, not just in the UK, but internationally and is now in its 6th edition. The first was published in 1988 with Briony as Editor and author of a large number of the chapters. She continued as Editor for the next three editions and, being a scientist and dietitian herself, was able to choose appropriate authors as the book developed. Briony was made a BDA Fellow in 1994 and appeared on the BDA roll of honour 2007 for her contribution to dietetics through what has fondly become known as The Manual. To quote one tribute: “Briony was The Manual”. The profession owes her a great debt of gratitude for leaving such a legacy. For the full obituary written by Dr Jacki Bishop, along with Briony’s husband Dick Thomas, please visit www.NHDmag.com/briony-thomas

www.NHDmag.com August/September 2019 - Issue 147

CLINICAL

ILEOSTOMY/COLOSTOMY MANAGEMENT: THE FOUR Fs IN STOMA CARE This article focuses on the key aspects of care for patients with stomas.

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

A stoma, with the literal meaning of ‘mouth’ in Greek, is an opening which (in this context) connects the small or large intestine to the outside of the body, so waste products may be removed and emptied into an external bag attached to the skin.1 Approximately 13,500 people in UK undergo surgery for a stoma every year2 and its management may have an immense impact on physical and mental health. FORMATION

Here are a number of reasons why a patient requires a stoma, often linked to diseases such as:1 • inflammatory bowel disease (Crohn’s, ulcerative colitis) • bowel cancer • diverticulitis • bowel obstruction • ischaemic bowel • abdominal trauma • anal stenosis • faecal incontinence The surgery will either remove the diseased part of the bowel, or provide a period of rest for a section of the bowel to recover from inflammation. Therefore, stoma formation may be

permanent or temporary. The two most common stomas are a colostomy (where the colon is connected to the skin opening) and an ileostomy (the ileum, the last part of the small intestine, is connected to the skin opening). Table 1 below outlines the different colostomy and ileostomy that may be formed. FLUID

Dehydration is common, in particular in patients with ileostomies who have had large amounts of their ileum removed, and can often result in a readmission to hospital and acute renal failure.4 Post-operatively, the most common losses seen in ileostomy patients are fluids and sodium. This is particularly seen in patients who have had a total colectomy, as this means that the entire colon has been removed, where most of the fluid and sodium is normally absorbed. Within the first six to eight weeks especially, patients may lose 12002000ml fluid and 120-200mmol sodium/ day. After eight weeks, the ileum then adapts to absorb, and fluid losses usually reduce to 400-600ml/day.1 Due to the loss of sodium, patients are also encouraged to add salt to their diet.

Table 1: Colostomy and ileostomy procedures1 Loop colostomy End colostomy known as a Hartmann’s procedure Double barrel colostomy Temporary or loop ileostomy End ileostomy Continent ileostomy

The colon is sutured to the abdomen and there are two openings: one for intestinal waste and one for mucus produced by the GI tract. The sigmoid colon and upper rectum is removed; an end colostomy is formed. Both ends of the colon are brought out onto the abdomen. A loop of the small intestine is brought to the skin and the colon and rectum remain in situ. This is usually reversed 8-10 weeks later. The colon and rectum are removed and the end of the small intestine is brought through the skin. An internal pouch is created and the stoma is connected to a valve implanted in the skin, which can be emptied using a catheter.

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CLINICAL Table 2: The differences in surgeries that are performed to create the stoma3 Right hemi-colectomy Left hemi-colectomy Abdominoperineal resection Anterior resection Sigmoid colectomy Hartmann’s procedure Total colectomy Pan-proctocolectomy

Right half of the colon is removed. Left half of the colon is removed. Rectum and anus removed; colostomy formed. Removal of cancer in the rectum. Sigmoid colon removed; two ends joined together. Sigmoid colon and upper rectum removed; end colostomy formed. Entire colon removed; permanent ileostomy or small bowel will be joined to rectum. Colon, rectum and anus removed; permanent ileostomy formed.

Contrary to normal physiological function, patients with ileostomies are discouraged from drinking additional fluids to improve hydration. This comes as a result of the hypotonic nature of normal fluids (such as water, tea and cordials) and the leaky nature of the upper small intestine, meaning that patients can lose more fluid from their stomas than they consume. Patients with high output stomas, producing >1500ml/ day,5 are advised to limit hypotonic fluids to 1000ml/day and take an additional 1000ml from a rehydration solution, such as St Marks Solution or Dioralyte (made to double strength). These rehydration solutions help to prevent dehydration by replacing electrolytes. St Marks Solution can be made at home with the following ingredients: 1 level 5ml teaspoon salt 6 heaped 5ml teaspoons of glucose ½ heaped 2.5 teaspoon of sodium bicarbonate Mixed in 1L water Fluids are also discouraged from being taken with meals, ideally avoiding 30 minutes before and after eating, to minimise dehydration as a result of the gastric fluid production increasing fluid losses.6 Types of fluids should also be considered, as fizzy drinks can cause excess gas in stoma bags and, therefore, some patients choose to limit or avoid these. FIBRE

Dietary fibre can be described as a component of food, which includes ‘all carbohydrates that are neither digested nor absorbed in the small intestine and have a degree of polymerisation of three or more monomeric units, plus lignin.’7 In simpler terms, it is also known as the ‘roughage’ in our diet. It helps to regulate our bowel

movements and diets high in fibre have been linked to reducing the risk of diabetes and bowel cancer, as well as helping to lower cholesterol. It is usually advised that patients follow a low-residue (low-fibre) diet in the first six to eight weeks following both colostomy and ileostomy formation, but regarding diet following this period, there are few clinical trials to support any one in particular.1 Further advice tends to focus on adjusting foods depending on stoma function, for example, avoiding certain foods which are poorly digested and may cause a potential blockage (stoma obstructives), choosing lower fibre options if an increased output is noticed, or avoiding foods which cause more gas or odour. Patients should be encouraged to aim to return to a healthy balanced diet following eight weeks post-op if a normal output volume/consistency has been achieved. It is important to remember that fibre tolerance will be individual and dependant on the extent of surgery and normal GI function. Some patients may easily return to a diet high in wholegrains, beans and pulses, whereas others may have to reintroduce these foods at a slower rate, or limit some altogether. Healthcare professionals need to be able to support patients with this and encourage the reintroduction of fibre once it is appropriate to do so. For patients who have had surgery for cancer, constipation may occur due to medication use, reduced activity, or poor diet and fluid intake. Ensuring that patients who are suffering with constipation have adequate dietary fibre (beware of stoma obstructives) and fluids, can help to improve GI function.8 For patients with a high or loose output, a low-fibre diet has been shown to improve output www.NHDmag.com August/September 2019 - Issue 147

CLINICAL Table 3: Food examples High-fibre foods Wholemeal bread, whole fruits, brown pasta, rice, whole vegetables, nuts, seeds, wholegrain cereals (Shredded Wheat, Bran Flakes) Stoma obstructives Apple peel, sweetcorn, chinese vegetables, dried fruit, nuts, mushrooms

consistency and volume and should, therefore, be advised.9 FOLLOW-UP

Stoma formation is a major surgery and comes with a great deal of aftercare and certain skills are required, therefore, it is vital that patients have the correct support and follow-up postoperatively. Stoma nurses play a crucial role in teaching skills such as stoma care and changing stoma bags; research has shown that the early promotion of stoma-management skills improves the psychological adjustment that is required following a stoma formation.10 Further studies also suggest that this should be continued upon hospital discharge, as the need to acquire all practical skills for stoma care within the short period of hospitalisation may lead to psychological distress among patients, as well as experiences of anxiety, fear and insecurity.11,12 As a result, preparation for discharge is considered a stressful event for many patients and psychological support should be provided alongside post-operative education.13 Despite these suggestions, experiential evidence has shown that this does not always occur, due to staff shortages and increased workloads.14 There have been a number of studies looking further into the psychological effect that stoma surgery can have on a patient, concluding that it can often lead to a series of physical and psychological stresses, as well as maladjustment and poorer health outcomes.15-17 Common impacts include altered body image, the loss of body function, decreased self-esteem and perceived self-care difficulties. Patients with a stoma also have significantly higher levels of depression than those without.18 The type of surgery should also be considered when offering psychological support, as several clinical studies have reported that patients who have emergency stoma surgery may have greater 38

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Low-fibre foods White bread, peeled fruits without pips/piths, eg, pears, peaches, banana, melon, white pasta, rice, peeled vegetables - cooked well and mashed, smooth nut butters, white cereals (Cornflakes, Rice Krispies, Cocoa Pops) Gas producing Beans/pulses, cabbage, broccoli, cauliflower, alcohol, onions

difficulty adjusting to the sudden body image change and functional loss, due to the fact that patients have little time to anticipate or accept their future living with a stoma.13,19 Therefore, patients admitted for emergency surgery are at a higher risk of suffering from stress and psychological distress, which can affect future coping and recovery,19 whereas patients admitted for elective stoma surgery may anticipate the loss and grief process after the surgery.19 These findings emphasise the importance of nurse assessment of a patientsâ&#x20AC;&#x2122; mental health and the need to provide relevant psychosocial care for a patient following stoma surgery. Follow-up is also required to ensure that patients are not nutritionally compromised following surgery. As well as managing stoma output and hydration, some vitamin/mineral replacements may need to be considered. Following a total colectomy, the absorption of other nutrients should be unaffected and the absorptive capacity of the small intestine remains intact. A small number (3-9%) of patients have been estimated to suffer from vitamin B12 deficiency and some patients may find absorption of bile acids are also affected. This is thought to be due to reduced absorptive capacity due to ileal involvement, inadequate dietary intake or bacterial overgrowth. As the ileum contains B12 receptors and bile salt transporters, those patients who have had ileal resection often suffer from B12 deficiency and fat malabsorption. Fat malabsorption may lead to steatorrhea and deficiencies in fat soluble vitamins A, D, E and K.20-22 CONCLUSION

Dietitians can play a key role in supporting stoma patients to achieve a healthy balanced diet, avoid nutritional deficiencies, achieve optimal consistency and prevent dehydration.

SKILLS & LEARNING

DEVELOPING A DIETETIC SERVICE Trying to set up a new dietetic service or developing an existing one can seem overwhelming, and pressures in the NHS may mean that doing this isn’t always feasible. This article discusses the factors that I considered for setting up a dietetic service to high output stoma patients. When I was a Band 5 dietitian working on the acute medical assessment unit, I became increasingly aware of high output stoma patients being admitted with dehydration. They were hydrated with intravenous fluids (IV) and sent home a day or two later, but would often find themselves back in within a few months. I wondered if the individuals had been given any information on how to manage a high output stoma: was it the ‘norm’ for them and did they know how to start to manage it? With these questions in mind, I started to capture data to identify any trends. I started to screen for patients who were admitted with the presenting complaint of dehydration. I then looked to see who had a jejunostomy, ileostomy, or colostomy. This created my data collection patient sample. Referral to the dietitian was often not made for the patients in this sample and if a referral was made, it was not guaranteed that the dietitian saw the patient prior to their discharge, due to prioritisation of caseload. Looking at this retrospective data, I had the idea that if all jejunostomy, ileostomy and colostomy patients were provided with education on ‘how to manage their stoma output’, it may help with preventing these hospital admissions with dehydration. That formed the initial aim of my service, to contribute to preventing recurring hospital admissions with dehydration due to a high output stoma. I realised

that in order to achieve this aim, I would need to work closely with key stakeholders. ENGAGING WITH KEY STAKEHOLDERS

I arranged a meeting with the stoma nurses and a colorectal surgeon at the trust and discussed my data findings. We were all in agreement that multidisciplinary team (MDT) working to educate and support this group of patients could only be beneficial to their patient experience and would hopefully prevent admissions with problems associated with stoma management. We discussed that I would see all jejunostomy, ileostomy and colostomy patients for dietary advice. (All jejunostomy patients were already seen by a senior dietitian due to the increased requirement for parenteral nutrition.) We realised that I would need to provide ‘troubleshooting’ information to all patients who had an ileostomy, on how to manage a high stoma output should it ever develop in the future, so that they were informed and prepared.

Louise Edwards Specialist Dietitian, Community Team Lead Louise is a Specialist Dietitian working for the Central Cheshire Integrated Care Partnership (CCICP). She is the Community Team Lead and is passionate about service improvement.

REFERENCES Please visit the Subscriber zone at NHDmag.com

MULTIDISCIPLINARY TEAM (MDT) WORKING

Previously, the stoma nurses and dietitians worked minimally together, with the dietitians providing education at a support group a couple of times a year. After discussing the data I had collected, we were all driven to improve the service to this patient group. It was agreed that the nurses would refer to www.NHDmag.com August/September 2019 - Issue 147

SKILLS & LEARNING

As part of the service, it was agreed that dietetics would provide an urgent service clinic, so that patients could be reviewed within one week of discharge from hospital.

me when a new stoma was formed during bowel surgery and we would aim to do a joint visit to introduce our newly formed ‘MDT’ and for me to provide my newly designed diet sheet on ‘troubleshooting for your ileostomy’. This diet sheet aimed to recognise signs of dehydration, ways to thicken output and fluid management, etc. Within the MDT, we had the support of a colorectal surgeon who was happy to be our ‘go to’ consultant when we needed to discuss any individuals who we were really concerned about post-operatively. As part of this newly formed MDT, we decided to implement a weekly ward round, seeing predominantly the high output ileostomy patients. Whilst doing the rounds, it became clear to me and the stoma nurse that the variability in the management plan for a high output ileostomy patient depended on the doctors that had seen them and what ward they were on, etc. Again, I data collected this information looking at: • the length of time before medication to reduce output was initiated; • the dosage of the medication and how many times a day it was prescribed; • the rate at which the medication dosage was increased, etc. The colorectal surgeon was surprised by the variability in these management plans and asked that I present the findings to all the general and 40

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colorectal surgeons at the Trust, which I did. This presentation was well received and the consensus was to look at creating a standardised protocol for the management of a high output stoma. BENCHMARKING

To consider creating a standardised guideline, I thought about the term ‘benchmarking’: seeking out and implementing best practice.1 I contacted local Trusts and specialist centres to see if they had a standardised pathway for management of high output stomas to create a guideline that they felt would work in the Trust. The surgeon and I reviewed literature around management plans of high output stomas with Baker et al (2010)2 being a great source of information. Once all this had been collated, I sat with the colorectal surgeon and a gastroenterologist to create a pathway that they felt would work in the Trust. This guideline had to be ratified at the relevant governance meetings and input from pharmacy was essential for instruction on the medications involved. The surgeons felt that this guideline supported doctors at all levels in their training in prescribing medications for a high output stoma. As part of the weekly MDT ward round, the stoma nurse and I were able to highlight to the medical/surgical team whether a management plan was put in place that differed from the guideline.

SKILLS & LEARNING OUTPATIENT CLINICS

Patients were often discharged from hospital with a management plan for a high output stoma. As part of the service, it was agreed that dietetics would provide an urgent service clinic, so that patients could be reviewed within one week of discharge from hospital. I had to locate an appropriate clinic room in the hospital and work with the administrative support to set up 30-minute clinic appointments for all patients. Following the trust policy, as a Band 6 dietitian, I was able to order bloods to assess hydration status and magnesium levels and was able to discuss these results with the consultant surgeon. This close working ensured that any patient who the surgeon was concerned about could be brought through to the surgical assessment unit for further review. In this clinic, I saw all stoma patients post-discharge and I used outcome measures to capture the patient experience of the service. OUTCOME MEASURES

An outcome measure is defined as the ‘change in the health of an individual, group of people, or a population which is attributable to an intervention, or series of interventions.3 Creating outcome measures for this service was important to support decision-making and to demonstrate that it was a key service that made a difference to an individual’s health and quality of life.3 Patient reported outcome measures (PROMS) were implemented with a LIKERT scale of 1-10 for patients to rate the degree of their symptoms.4 For some, wind was their main concern, for others constipation, or odour for some high output. Reviewing these outcome measure results at

the start of the consultation supported tailoring dietary advice to the individual’s priorities. CONTINUING PROFESSIONAL DEVELOPMENT (CPD)

Once the outpatient clinic was well established, it formed a fundamental part of CPD for the Band 5 dietitian, who I supervised in the gastroenterology/surgical rotation. The Band 5 was invited to shadow me in clinic initially, and then progress to seeing patients with indirect supervision. Reflecting on the service was continuous and before I left the Trust, there was still potential to develop it, for example, the stoma nurses and I discussed setting up a ‘pre-op bowel school’ to provide education and awareness of what individuals could expect after bowel surgery. My initial aim of the service was to contribute to preventing recurring hospital admissions with high output stomas. As the service developed, other aims were identified, such as standardising the medical management of a high output stoma patient and contributing to reducing length of hospital stays post-surgery. It is likely that this service will continue to evolve with feedback within the MDT and feedback from outcome measures. It is my own professional value to strive for service improvement for patients and I have been fortunate in my working career so far that the Trusts I have worked for have strived for this also. I would like to thank the dietetic team, stoma nurses and surgeons at the Countess of Chester Hospital for their input and support on developing this service. I would also like to thank Melanie Baker, RD for her valuable clinical experience.

Continuing professional development To view our latest NHD CPD eARTICLE please visit NHDmag.com www.NHDmag.com August/September 2019 - Issue 147

COMMUNITY

ORAL NUTRITIONAL SUPPLEMENTS: APPROPRIATE PRESCRIBING FOR A CLINICAL NEED Martha Hughes, Scientific and Regulatory Executive, BSNA Martha is an Associate Nutritionist with a degree in Nutrition from the University of Surrey. She has research and regulatory experience in specialist nutrition.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Nutrition is imperative to our existence and over the years the awareness of the importance of good nutrition has increased, including the role nutrition can play in preventing and managing disease and medical conditions. High quality nutritional care should be at the heart of patient care but, in reality, it is still often ignored. Nutrition is available on prescription in many forms, for those who suffer from a disease, disorder, or medical condition and when normal food alone, however nutritious, is not sufficient to meet a person’s dietary needs. These products, available on prescription, otherwise known as nutritional borderline substances, are specifically formulated to meet disease-specific indications, which are set out by the Advisory Committee on Borderline Substances (ACBS).1 The ACBS is responsible for ensuring that the products are safe and appropriate for the treatment of specified conditions. Nutritional borderline substances include Foods for Special Medical Purposes (FSMPs), which are evidencebased nutritional solutions for a range of diseases, disorders and medical conditions for all ages. FSMPs include ONS and enteral tube feeds. As with all prescriptions, these should all be used under the supervision of a healthcare professional. MALNUTRITION

Malnutrition continues to be a serious problem in the UK, estimated to affect at least three million people,2 around 98% of whom are living outside the hospital setting. Malnutrition and dehy42

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GUIDANCE ON ONS ONS is supported whenever there is a clinical need by the following: • NHS England Guidance on Commissioning Excellent Nutrition and Hydration 2015-2018 •

NICE Clinical Guideline 32 on Nutrition Support in Adults (CG32)

•

NICE Quality Standard 24 (QS24)

dration are both causes – and usually consequences – of illness, thus ensuring that patients receive adequate nutrition is critical for improving their overall health outcomes. Malnutrition remains a growing problem, yet is largely preventable and can be better managed if the right guidance is followed. The effective management of malnutrition could have a significant impact on the health economy, as the annual health and social care costs associated with malnutrition are estimated to be nearly £20 billion in England alone.3 The potential cost saving of implementing nutrition support in adults is ranked as the third highest amongst a wide range of other cost saving interventions.3 As recognised by NHS England’s Commissioning Guidance on Nutrition and Hydration,4 malnutrition can result in increased demand for GP and out-of-hours

COMMUNITY services, increased hospital stays and decreased quality of life.5 Unfortunately, however, all too often nutrition support guidelines and standards are forgotten or ignored, even though NHS England’s 10 Key Characteristics of Good Nutrition and Hydration Care6 require that, ‘all care providers have a nutrition and hydration policy centred on the needs of users, [which is] performance managed in line with local governance, national standards and regulatory frameworks’. Malnutrition can affect all ages, but it is particularly prevalent in later life. Malnutrition is caused by insufficient dietary intake with disability and disease at the heart of the problem.7,8 Food intake is often reduced because of the effects of disease and its treatment, for example poor appetite, swallowing difficulties, the side effects of drugs, or physiological reasons. As a consequence, patients and families suffer; patient’s quality of life is adversely affected; there’s an increase in hospital admissions and readmissions, increased mortality and mortality rises.9,10 It costs more not to treat malnutrition than to do so. In a report from 2015, the British Association for Parenteral and Enteral Nutrition (BAPEN) and the National Institute for Health Research Southampton Biomedical Research Centre (NIHR) estimated a cost difference of £5329 more in treating a malnourished patient, compared with treating a well-nourished patient.3 Moreover, the provision of nutrition support by implementing the National Institute for Health and Care Excellence (NICE) Quality Standard (QS24)11 and NICE Clinical Guidance (CG32)12 to 85% of patients at medium and high risk of malnutrition would lead to a cost saving of £325,000 to £432,000 per 100,000 people.3 MALNUTRITION SCREENING

It’s important to identify individuals who are malnourished, or at risk of malnutrition, using a validated nutritional screening tool, such as the ‘Malnutrition Universal Screening Tool’ (‘MUST’).13 NICE Quality Standard (QS24),11 NICE Clinical Guidance (CG32)12 and the Managing Adult Malnutrition in the Community Pathway14 all recommend a multidisciplinary approach to the identification of people at risk

of malnutrition and provision of timely nutrition support. This can include advice on eating well and food fortification, but for those where more support is needed, foods specifically formulated to meet nutritional requirements should be prescribed. MALNUTRITION PATHWAY

The Managing Adult Malnutrition in the Community Pathway14 is an evidence-based tool to assist in the appropriate use of ONS, which can be used across all care settings. It has been founded on clinical experience and evidence, alongside accepted best practice and has been endorsed by professional organisations such as the BDA, BAPEN, Royal College of Nursing (RCN) and Royal College of General Practitioners (RCGP). Visit www.malnutritionpathway. co.uk for more information on the pathway and updated supporting documents, all of which are downloadable, including the publication Managing Malnutrition with Oral Nutritional Supplements (ONS) – advice for healthcare professionals. NUTRITIONAL SOLUTIONS FOR DISEASE MANAGEMENT

Medical nutrition can be used from birth until old age. If a patient is able to feed orally, nutrition support can take the form of ONS. ONS are evidence-based nutritional solutions for disease-related malnutrition, helping to improve patient quality of life and significantly reduce hospital admissions and readmissions, along with a reduction in the length of stay. NICE QS2411 recognises that ONS are a clinically effective way to manage disease-related malnutrition when food alone is not sufficient to meet a person’s dietary needs. It also advises that care should be taken when providing food fortification alone, which tends to supplement energy and/or protein without necessarily providing sufficient or adequate micronutrient and mineral levels. Patients who require medical nutrition, including ONS, can have a wide variety of conditions and can include those who are critically ill, to those with inherited genetic disorders and to those with chronic illnesses, such as cancer, kidney failure, cystic fibrosis, diabetes, sarcopenia and respiratory disease. www.NHDmag.com August/September 2019 - Issue 147

COMMUNITY

High quality nutrition support should be at the heart of patient care.

In addition, specialist disease-specific medical nutrition may be required for people with inborn errors of metabolism, those with food allergies, or patients with dysphagia. For those who struggle to feed orally, enteral feeds (including ONS) can be administered via the gastrointestinal tract, either by a nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG). ONS can be an essential part of medical management for disease-related malnutrition and may be required either for life or for short periods of time, depending on the individuals’ clinical circumstances. In these cases, they guard against malnutrition until a normal diet can be resumed. POWDER OR LIQUID ONS?

ONS are available in two different forms: powders (which are made up to form a liquid), or ready-made liquids. The decision about which form to prescribe is an important one and should be carefully considered. Both have their advantage, but ultimately the decision about which is the best option should come down to the specific clinical circumstances and requirements of the patient; there is no blanket approach. Factors to consider might include the level of the patient’s dexterity, mobility and sight and: whether they can tolerate volume; can tolerate milk; are able to make up the product accurately; are able to swallow safely; and their individual preferences. A helpful checklist can be found at BSNA.co.uk.15 VARIATION IN PRESCRIBING ACROSS THE UK

Despite all the guidance and evidence surrounding the clinical value of ONS, there is variation in prescribing practice across the UK. Some Clinical Commissioning Groups (CCGs) have restricted the prescribing of ONS, 44

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. . . poor nutrition can have many negative consequences, both in the short and longer term.

especially in care homes. It is not only important to address the health of the patient, but also the time restrictions caregivers may have in a care home setting. ONS can be a lifeline in the community and care homes, where round-theclock care may not be available. Those who can clinically benefit from prescribed ONS need to have access to the products. ONS is not designed as a food or meal replacement, but is a supplement of macro- and micronutrients to any food or other oral intake which can be tolerated by the patient as per national guidelines. Prescribed appropriately, ONS can prevent the complications associated with malnutrition and resulting increased demand on healthcare resources, eg, hospital admissions, along with significantly improving patients’ health outcomes, whilst offering a clinical and cost-effective solution. CONCLUSION

High quality nutrition support should be at the heart of patient care. The nutritional status of patients who have a disease, disorder or medical condition, should always be considered as part of a patient’s care management strategy. It is important for healthcare professionals to be able to recognise when it is appropriate for nutrition to be prescribed, as poor nutrition can have many negative consequences, both in the short and longer term. Appropriate prescribing can also result in long-term cost savings to the NHS and enhanced patient outcomes. Its positive impact on overall health and recovery should not be underestimated. CCGs should align their policies against national recommendations to ensure prescribing of nutritional borderline substances is appropriate, based on clinical need, and to reduce unwarranted variation in patient care.

A DAY IN THE LIFE OF , , ,

A COMMUNITY NUTRITION SUPPORT DIETITIAN Having reflected on her diary in order to write this article, Laura can honestly say that no two weeks as a Community Nutrition Support Dietitian are the same. It’s a busy and varied role that is challenging and satisfying at the same time. Monday starts with catching up on emails, including one from an integrated care team (ICT) manager enquiring about the best weighing scales to purchase, and another from a care home manager asking about step 2 of ‘MUST’, which so many homes struggle with; I make a note to cover this at our next care home forum. I manage to book in a couple of home visits and then head off after lunch to run a training session for integrated care colleagues, including nurses and support workers, focusing mainly around the nutritional needs of older people, such as screening for malnutrition and interventions to treat it. Educating healthcare teams and care homes is vitally important, as they are the ‘eyes and ears’ on the ground, often the first to spot potential nutritional issues. They all seem really motivated about putting their new knowledge into practice. HOME VISITS

The next day is a much more clinical affair. I visit a young man with cerebral palsy who lost a lot of weight after developing volvulus (twisted bowel) and eventually required surgery. He’s doing really well, so I provide him and his live-in carers with lots of ‘food-first’ advice and tweak his supplement prescription to hopefully encourage some weight gain. A nursing home is next on the list, where I visit a 91-year-old lady who has advanced dementia and is immobile, unable to communicate verbally and needing one-to-one assistance with all aspects of care. She is not eating and drinking very well anymore and has lost over

10kg in the past year. Her family are there and want to know if she is going to get better. These conversations are always tough, as the irreversible nature of dementia means that improvement is unlikely; however, the family takes comfort from knowing that we can still focus on her quality of life by spending time with her and ensuring that she is comfortable and pain free. The afternoon is busy with telephone reviews. Not everyone picks up, so I leave messages and hope I can catch up with them soon. I find out that a patient who has Huntingdon’s disease and who I’ve been seeing at home for nearly a year, has been in hospital after a fall that resulted in a head injury and who now needs residential care. I get in touch with the home to hand over some history and arrange to review the patient in a few weeks once she is settled. On the flip side, a daughter looking after her mum at home with vascular dementia cannot thank me enough, as she has noticed a huge improvement with her mum’s cognition, mobility and bowels after implementing foodfirst advice and getting her supplement prescription sorted. This lady wasn’t well at all when I visited, so I’m chuffed to hear the impact on her quality of life, with her weight stabilising, is a bonus.

Laura Sexton RD Community Nutrition Support Dietitian, Frimley Health NHS Foundation Trust Laura has worked predominately in the community since qualifying in 2011. Her current role combines clinical nutrition support alongside prescribing support for two CCGs. She is also the meetings organiser for the BDA’s Older People Specialist Group.

REFERENCES Please visit the Subscriber zone at NHDmag.com

MDT MEETINGS

Wednesday begins in the hospital dietetic department where I finish yesterday’s letters and pick up new referrals. I meet with our students on their C placement who are doing some retrospective data collection for me to look at community www.NHDmag.com August/September 2019 - Issue 147

CAREER patient referral demographics and outcomes. They have learnt a lot about the nature of community dietetics just from trawling through my notes and they give me some useful ideas for future data collection. After lunch, I attend an ICT MDT meeting, where a variety of different health and social care professionals discuss the management of complex patients living in the community. There are no referrals for me this week, but I catch up with members of the team who are also involved with some of my patients. Being able to have these face-to-face conversations in the community is so refreshing, as we usually rely so much on telephone calls and emails. My last visit of the day is with a community matron to a patient with vascular dementia who is living alone. This will be followed up by a best interests meeting next week when we will discuss his future living arrangements. The patient seems stable, but it is difficult to assess how much he is eating from carer notes, and there’s a half finished meal (presumably lunch) left by his chair. In the medicines management team meeting the next morning, I update everyone on progress with IDDSI in the community, which has raised some significant challenges, particularly around the quality of thickener prescribing. We also discuss vitamin D and vitamin B prescribing in primary care and review some new guidance documents for GPs. The pharmacists are appreciative of my ‘outsider’ knowledge and experience and I, again, reflect on how satisfying it is to work collaboratively with different professions.

Q&A SESSION

I head off to speak at a local mental health service group for people with young onset dementia and their carers. A formal presentation didn’t feel appropriate, so I opt for a relaxed Q&A session which goes down better than expected, as they are all keen to talk and support each other. We cover many of the nutritional challenges associated with dementia, such as changes in taste, behaviour, memory and physical ability, and I realise how powerful it is to hear personal experiences first-hand, rather than just reading the theory in a textbook. Throughout the day I have received several voicemails, so I spend the rest of the afternoon calling people back and am able to complete a few more telephone reviews. On Friday morning, I join a teleconference with our CCG Quality in Care Homes team to discuss the upcoming care home forum. I have a regular slot where I talk about anything and everything that care homes might find useful, but as the next forum is about pressure ulcers, I’m also asked to do something on nutrition and wound healing. I see it as a useful opportunity for me to look at the latest guidance and refresh my knowledge, so, hopefully, I can squeeze in some preparation time next week. The rest of the day is office-based, but there are plenty of telephone reviews to finish, new referrals to triage and visits to book in, plus all the inevitable admin that follows!

dieteticJOBS.co.uk • Quarter page to full page • Premier & Universal placement listings • NHD website, NH-eNews and Network Health Digest placements To place an ad or discuss your requirements:

01342 824 073 46

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REFLECTING ON DIETITIANS WEEK Dietitians Week 2019 seemed to have been bigger and better than the last. This year the focus was on #WhatDietitiansDo. A simple idea, but as the public perception is that all dietitians just give out weight loss advice, this year’s focus was an effective one. Many dietitians who took part went on social media, especially Twitter, to tell people what they did each day. Some dietitians increased their profile by heading to the wards wearing colourful T-shirts, to promote the work of dietitians. Others even had nasogastric tubes passed! There was a lot of promotion to the public going on, with stands and events and so much more. At our Trust, the planning had been in full swing months before. We decided on a mainly social media strategy, with different themes each day. Our manager even persuaded the Communications department to let us take over the Trust Instagram account for the week. This is moving into new territory for us. We have a therapy Twitter account which we use regularly, but Instagram is different. It is more about storytelling. Our Communications department entrusted the account to me and said that I had free reign to do what we wanted (within the Trust’s social media policy, of course!). This was exciting. My colleagues had done a great job of collating lots of photos for each day. Our themes included: what other colleagues think dietitians do, what dietitians eat, nutritional assessment, nutrition champions and dietitians in research. Instagram has a different style to short sharp twitter. The photo is one part of it, but a good story to go with it is essential. Taking time to prepare these posts and then scheduling them was important.

Louise Robertson Specialist Dietitian

The 'Insta-story' side was fun: talking to myself in my office and capturing other dietitians at work. I even managed to persuade my IMD team down in clinic to appear on it as well. But, never would I have thought that we would do an Insta-live during work, especially on the Trust account! I managed to persuade a couple of my social media savvy colleagues to take part with me. We planned it for Tuesday at 1.30pm and promoted it beforehand. We prepped some questions and then filled the room with dietetic props. With adrenaline surging, we decided on a conversational style approach with each other, discussing what we did in our jobs and how we became dietitians. Our 15-20 minutes was up in no time. We even had a live question asked! It was very satisfying and motivating to make ourselves more approachable during the week. I think that sometimes, as clinical dietitians, we are worried about putting ourselves out there, but we shouldn’t be - we know our stuff! I was also involved in a group of freelance dietitians who helped produce a recipe book for charity. The idea and group were led by Anne Wright, an experienced freelance dietitian with a drive to see the project through. We all submitted our family-friendly recipes and then Anne created an e-book, launched during Dietitians Week with the support of the BDA. We raised £1420 in support of The Trussell Trust - a great achievement! Roll on next year.

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

To see what we got up to on the Trust Instagram account, check out @uhbtrust on Instagram.

www.NHDmag.com August/September 2019 - Issue 147

Oral nutritional supplements (ONS) might contain milk protein, but that doesnâ&#x20AC;&#x2122;t mean they all have to taste like milk. If your patients are getting bored with their milkshake-style ONS, why not try them on Ensure Plus juce? It packs balanced nutrition into a refreshingly different juice-style supplement, and comes in a wide range of flavours, so thereâ&#x20AC;&#x2122;s always a taste to match theirs. ENSURE PLUS JUCE. FOR MORE INFORMATION, VISIT OUR WEBSITE NUTRITION.ABBOTT/UK

Date of preparation: May 2018 ANUKANI180120b

Like all juice-style ONS, Ensure Plus juce contains milk protein, and is not suitable for patients on a milk protein restricted diet.