Network Health Digest: October 2019 NHD

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

ACTIVATED CHARCOAL

NHDmag.com

October 2019: Issue 148

WEIGHT MANAGEMENT SERVICES AND OBESITY

EOSINOPHILIC OESOPHAGITIS BACTERIA: THE GOOD AND BAD UNDERNUTRITION DYSPHAGIA WEANING AND CMPA PUBLIC HEALTH MESSAGES IMD WATCH

BREASTFEEDING

Pages 35-37

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Date of preparation: August 2019 ANUKANI190238

NHD Editor, Emma Coates, in her new Up Front column, reflects on the latest government review on hospital food and asks, “Why Prue?. . .

October sees the return of shorter days and chillier nights, but we are nearing the culinary treat that is the final of The Great British Bake Off (GBBO), which hopefully won’t result in any exploding ovens, or showstopper disasters!

“Millions wasted on ‘unpalatable’ hospital food”, is not something you’ll hear on The GBBO, but this was a recent comment made by celebrity chef and Bake Off judge, Prue Leith, as the government announced the launch of its latest hospital food review.

The standard of food in our hospitals is a hot potato, which has been reviewed, discussed and often criticised for many years. Yet, little seems to have improved.

With any large-scale production of food, it’s a challenge to meet the diverse needs of many recipients and within budget. However, when it comes to hospital food, there really isn’t much room to manoeuvre, as the diversity of needs must be met and it’s unacceptable to provide poor quality food to some of the most vulnerable in our society.

Prue has been taken on as advisor to the government regarding this review.

She is not the first celebrity chef to get on board with such schemes. Albert Roux, Lloyd Grossman and James Martin are all previous famous chefs who’ve taken a run at this mammoth task, and don’t forget Jamie Oliver’s intervention. So, why will this review be any different? Well, the government has pledged to look into the positive impact of good quality food on aiding faster recovery, which will be supported by referring to case studies from across the

UP FRONT Emma Coates Editor

country. It will also consider the potential use of new systems to monitor food safety and quality, which includes more transparent methods for regular review and looking at how NHS boards are held to account.

Additional aspects of the review also include how to increase the number of hospitals with their own chefs and kitchens. The government is seeking support from national bodies and they will work together to potentially reduce reliance on repacked or frozen options, with the aim to source food and services locally. Eventually, the aim is to ensure that the 140 million meals served to patients across the country every year, are healthier, tastier and patient choice is greater, along with new national quality standards for the food served to staff, patients and visitors.

But why choose Prue? Whilst she is a well-established celebrity chef and television judge, is she really the right choice for this job? Former Chair of the School Food Trust and restaurateur with a CBE, Prue has previously spoken out on the need for hospitals to provide healthy, nourishing and filling options to aid recovery and for meals to be tailored to the individual needs of the patient. But, only time will tell.

Whether this latest review of hospital food will result in positive changes remains to be seen, but we can wait with optimism that this time it might be different.

Enjoy all the nourishment this issue of NHD has to offer. Emma

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

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11 COVER STORY Weight management services and obesity 6

News

8

Public health messages

Latest industry and product updates

43 PKU New research into weaning

For a healthy diet

16 EOSINOPHILIC OESOPHAGITIS 19 Dysphagia Causes and

management

23 Undernutrition Prevalence in the UK

31 Bacteria The good, the bad and the ugly

44 IMD watch The role of

Sapropterin

47 DIET TRENDS: ACTIVATED CHARCOAL 50 F2F Interview with Dr Laura Thomas

52 A day in the life of . . .

A food and health development worker

35 BREASTFEEDING: DUTY OF HCPS

54 Events, courses

& dieteticJOBS Dates for your diary

39 CMPA The challenges of weaning

and job listings

55 Dietitian's life Eating out with restrictions

Copyright 2019. All rights reserved. NH Publishing Ltd. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

Editor Emma Coates RD

Advertising Richard Mair Tel 01342 824073

Publishing Director Julieanne Murray

richard@networkhealthgroup.co.uk

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

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NHD_dietetics

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 October 2019 - Issue 148

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SACN REPORT ON SATURATED FATS AND HEALTH The Scientific Advisory Committee on Nutrition (SACN) has published the final version of its report, Saturated fats and health.

In 2014, it was agreed that a review of the evidence on saturated fats and health was required, due to the ongoing scientific and media debate focusing on the relationship between saturated fats and cardiovascular disease (CVD).

The report, published in August 2019, confirms a saturated fat link to blood cholesterol and heart disease and concludes that there is no need to change current advice. Based on 47 systematic reviews and meta-analyses, SACN concludes that: • higher saturated fat consumption is linked to raised blood cholesterol; • higher intakes of saturated fat are associated with an increased risk of heart disease; • saturated fats should be swapped with unsaturated fats; • there is no need to change current advice that saturated fat should not exceed around 10% of food energy.

Professor Paul Haggarty, Chair of the Saturated Fats and Health Working Group of SACN, said, “Looking at the evidence, our report confirms that reducing saturated fat lowers total blood cholesterol and cuts the risk of heart disease. Our advice remains that saturated fats should be reduced to no more than about 10% of dietary energy.”

Read the full SACN report here: www.gov.uk/government/publications/saturated-fats-and-health-sacn-report

HIGHLIGHTING THE ROLE OF REGISTERED NUTRITIONISTS. We have recently received feedback from a reader who was keen to highlight that in addition to Registered Dietitians, Registered Nutritionists (RNutr) and Registered Associate Nutritionists (ANutr) are suitably qualified to give dietary advice to patients.

The feedback precipitated from our article Eating disorders: the potential impact of dietary advice, published in our August/September issue, where it was stated that only dietitians are qualified to give dietary advice and only dietitians are regulated.

Whilst the publishers of NHD recognise that there are areas of dietary advice only dietitians can manage and the AfN code of practice is very clear on this, we also acknowledge the value and qualifications of Registered Nutritionists and Registered Associate Nutritionists.

We apologise for the misinformation within the article in question.

For further information about Registered Nutritionists (RNutr) and Registered Associate Nutritionists (ANutr) and the UK Voluntary Register of Nutritionists (UKVRN) visit: www.associationfornutrition.org/default.aspx?tabid=76

If you have important news or research updates to share with NHD, or would like to send a letter to the Editor, please email us at info@networkhealthgroup.co.uk We would love to hear from you.

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NEWS NICE GUIDELINES HYPERTENSION IN ADULTS: DIAGNOSIS AND MANAGEMENT (NG136).

Published in August, this guideline covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over, including people with Type 2 diabetes.

It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively.

This guideline includes new and updated recommendations on: • diagnosing hypertension; • starting antihypertensive drug treatment; • monitoring treatment and blood pressure targets; • choosing antihypertensive drug treatment; • who to refer for same-day specialist review.

This guideline updates and replaces NICE guideline CG127. It also updates and replaces the section on blood pressure management in the NICE guideline on Type 2 diabetes in adults (NG28).

NICE has also produced a guideline on hypertension in pregnancy.

Read more at: www.nice.org.uk/guidance/ng136.

Results from a prospective EPIC-Oxford study show that UK adults who are fish eaters or vegetarians have lower risks of ischaemic heart disease than meat eaters, but that vegetarians have a higher risk of total stroke.

Vegetarian and vegan diets have become increasingly popular in recent years, but the potential benefits and hazards of these diets are not fully understood. Previous studies of two diet groups have reported that vegetarians have lower risks of ischaemic heart disease than nonvegetarians. However, no evidence has been reported on a difference in the risk of mortality from stroke, possibly because of limited available data and lack of available evidence on stroke subtypes.

The Oxford study showed that fish eaters and vegetarians (including vegans) have lower risks of ischaemic heart disease than meat eaters. However, vegetarians (including vegans) have higher risks of haemorrhagic and total stroke than meat eaters.

Future work should include further measurements of circulating levels of cholesterol subfractions, vitamin B12, amino acids and fatty acids in the cohort, to identify which factors might mediate the observed associations. Additional studies in other large-scale cohorts with a high proportion of non-meat eaters are needed to confirm the generalisability of these results and assess their relevance for clinical practice and public health.

RISKS OF TOTAL STROKE IN VEGETARIANS STUDY

Read more at: www.bmj.com/content/366/bmj.l4897

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PUBLIC HEALTH

Dr Michele Sadler Consultant Nutritionist, Rank Nutrition Ltd Michele is Director of Rank Nutrition Ltd, which provides nutrition consultancy services to the food industry.

Michele has a BSc in Nutrition (University of London), a PhD in Biochemistry and Nutritional Toxicology (University of Surrey), and is a Registered Nutritionist.

REFERENCES Please visit the Subscriber zone at NHDmag.com

PUBLIC HEALTH MESSAGES FOR A HEALTHY DIET In response to increasing nutritional challenges, including the rise in the prevalence of obesity and Type 2 diabetes amongst other diet-related conditions, public health messages have an important role in educating the public about healthy eating. But is education alone sufficient to change public behaviour, and what is the future for such messages?

Public health messages for a healthy diet are the responsibility of Public Health England (PHE), an executive agency of the Department of Health and Social Care (DHSC). The role of PHE is to improve the health and wellbeing of the population and to reduce health inequalities, through the provision of evidence-based advice and scientific expertise. In fulfilling this role, PHE takes advice from the Scientific Advisory Committee on Nutrition (SACN), which consists of independent experts that advise government about nutrition science, diet and health.

UK government recommendations on diet and nutrition have tended to remain fairly constant over the years.

The most recent significant changes were in 2015 when the recommendation for maximum sugar intake was halved and the recommendation for fibre intake was increased.

EATWELL GUIDE

A cornerstone of public health messages about diet and nutrition is the PHE Eatwell Guide.1 This is based on reports from the former UK Committee on Medical Aspects of Food Policy (COMA)2,3 WHO4,5 and SACN.6-11 Updated in 2016, the pictorial Eatwell Guide summarises the key dietary messages in terms of five food groups for people aged five years and over (see Table 1 overleaf).

The Eatwell Guide also advises the public to eat sugary foods less often and in small amounts and drink six to eight glasses of fluid per day, including water, lower-fat milk, and sugar-free drinks such as tea and coffee.

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DIETARY SUPPLEMENT RECOMMENDATIONS

A number of public health messages recommend that targeted population groups should take specific dietary supplements (see Table 2 overleaf).

Folic acid and vitamin D supplements are recommended for these groups because it is difficult to get sufficient intake from food sources alone. Specific supplements are recommended for pregnant women on low incomes and small children, to ensure adequate intakes of particular vitamins that may be vulnerable in their diets.

COMMUNICATION OF PUBLIC HEALTH MESSAGES

A main vehicle for communicating PHE advice directly to the public is via the NHS website.15 Another means of reaching consumers is the Government’s advertising programme Change4Life,16 which aims to help families adopt healthier lifestyles by eating well and moving more. Health professionals and their associations such as the BDA, along with organisations such as the BNF, also have a pivotal role in communicating nutritional messages to the public. These organisations have an important role too, in interpreting scientific information and advice for journalists. Additionally, since the media, and more recently the social media platforms, are a major source of public information on diet and health, nutritionists working in the media also have a positive impact, ensuring that messages are scientifically accurate and consumer-friendly.

PUBLIC HEALTH Table 1: Key Public health messages in the Eatwell Guide* Food group Fruit and vegetables Potatoes, bread, rice, pasta and other starchy carbohydrates Beans, pulses, fish, eggs, meat and other proteins Dairy and alternatives Oils and spreads

Public health messages Eat at least five portions of a variety of fruit and vegetables every day.

Choose wholegrain or higher fibre versions with less added fat, salt and sugar.

Eat more beans and pulses.

Eat two portions of sustainably sourced fish per week, one of which is oily.

Eat less red and processed meat.

Choose lower fat and lower sugar options.

Choose unsaturated oils and use in small amounts.

*The Eatwell Guide does not apply to children under two years old and after this age, children’s diets should gradually adhere to the guidelines by the age of five years.

Table 2: Targeted dietary supplement recommendations Population group Women planning a pregnancy, from stopping contraception until the end of the first trimester of pregnancy Women with a previous neural tube defects-affected pregnancy, from stopping contraception until the end of the first trimester of pregnancy Children from one year of age, adolescents and adults, including pregnant and breastfeeding women Breastfed infants up to one year of age Bottle-fed infants up to one year of age consuming <500ml infant formula

Supplement

Aim

400mcg folic acid/day

To reduce risk of neural tube defects, such as spina bifida, in the foetus

5mg folic acid/day

As above

10mcg vitamin D/day, from October until April

To keep bones, teeth and muscles healthy

8.5-10mcg vitamin D/day

As above

8.5-10mcg vitamin D/day

As above

Children from birth to four years, consuming less than 500ml formula per day

233mcg vitamin A/day

Pregnant (at least 10 weeks) and breastfeeding women on benefits/tax credits; women aged under 18 years (start of pregnancy onwards) Women with heavy periods

ROLE OF HEALTH CLAIMS

20mg vitamin C/day 10mcg vitamin D/day 400mcg folic acid/day

For growth, vision in dim light and healthy skin To help maintain healthy tissue in the body As above As above

70mg vitamin C/day

As above

May need to take iron supplements

To reduce risk of iron deficiency anaemia

A further way in which consumers are exposed to positive dietary messages is via nutrition and health claims on food packs and websites.

The European regulation on claims17 is now firmly bedded in and only claims proven to be scientifically accurate are authorised for use.

Some claims back up public health messages, such as the disease risk reduction claim for folic acid supplementation that increases serum folate and reduces the risk of neural tube defects in the foetus.18

Interestingly, the claims regulation applies only to nutrition and health claims made in commercial communications and does not apply to claims made in dietary guidelines or advice issued by public health authorities and bodies. Hence, there is more freedom of communication for public health messages.

For example, the NHS website is able to refer to evidence that people who eat at least five portions of fruit and vegetables a day have a lower risk of heart disease, stroke and some cancers, whereas reference to disease is not www.NHDmag.com October 2019 - Issue 148

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PUBLIC HEALTH permitted on a food label, or on a related commercial website.

GAPS AND CHANGES IN PUBLIC HEALTH MESSAGES

While current public health messages are pretty comprehensive in addressing healthy eating advice and diet-related disease, a possible area for further public advice would be to address low micronutrient intakes in teenage girls.19,20 Whilst eating a diet that follows the Eatwell Guide will help to ensure adequate micronutrient intake, in this particular population group a targeted message may be helpful to reinforce the important contribution of specific food groups for ensuring adequate intakes of vulnerable micronutrients. For example, in years seven to eight of the NDNS Rolling Programme,20 54% of teenage girls (11-18 years) had iron intakes below the Lower Reference Nutrient Intake (LRNI), 22% had calcium intakes below the LRNI and 15% had folate intakes below the LRNI. There was evidence of both iron-deficiency anaemia (as indicated by low haemoglobin levels) and low iron stores (plasma ferritin) in 9% of teenage girls, as well as evidence of low blood folate levels indicating risk of anaemia in over a quarter (28%) of teenage girls. Targeting this population group is particularly important since teenage girls are future mothers. There is a growing body of evidence to support developmental origins of health and disease, ie, that undernutrition during gestation leads to foetal programming, which permanently shapes structure, function and metabolism and contributes to adult disease, potentially in more than one future generation.21 A further point raised in the literature is the appropriateness of the qualification that eating dried fruit should be limited to mealtimes. The advice is given in light of concerns that dried fruit may be harmful to teeth, but a review found very little evidence to support this.22 ARE PUBLIC HEALTH MESSAGES WORKING?

The current levels of obesity in the population and the rising tide of Type-2 diabetes, suggest that simply giving the public advice about diet and healthy eating is insufficient to encourage the adoption of healthy lifestyles. In recent years, other approaches have been adopted, such as 10

www.NHDmag.com October 2019 - Issue 148

the drive to remove excess salt and sugar from processed food, the sugar tax on soft drinks and the government’s childhood obesity strategy.

There is a view that a more interventionist approach is needed to bring about changes in the food supply and to help nudge people in the right direction. Professor Dame Sally Davies’s 10th Annual Report23 focused on the future health of England’s population. Taking an aspirational view of what good health could look like in 2040, the report considered changing behaviour in relation to diet, alcohol consumption, smoking and physical activity and concluded that an environment needs to be developed to make the healthy choice the easy choice in order to promote health. The report proposed a future aspiration that reform of the economic and commercial environment will lead to a shift in the food system from one incentivised by profitability, to one driven by healthiness and sustainability of food.

In this scenario, business growth would require a value-creating and health-enhancing approach, resulting in dietary benefits for the population.

Strategies to improve health could include fiscal measures that incentivise businesses to improve access to nutritious foods and disincentivise the production of energy-dense products. The report suggests that this could have a greater impact on health than interventions that focus on choices made by individuals.

CONCLUSION

In the face of increasing nutritional challenges, policy has moved forward such that public health messages are no longer the only measure for achieving population health through dietary change. Whilst they are a supportive educative measure, they now work alongside other strategies and approaches to help improve people’s diets. Should the future lead to the use of different and more interventionist public polices to improve health, the scientific basis of the public health messages will, nevertheless, remain a crucial part of policy, as these messages crystallise the underlying scientific basis for actions that might be taken and the aims of different policies. Hence public health messages will remain an important tool in the quest for achieving public health through improved diet and lifestyle.

COVER STORY

WEIGHT MANAGEMENT SERVICES AND OBESITY Worldwide obesity has nearly tripled since 1975 and the provision of NHS weight management (WM) services is likely to increase secondary to this. This article looks at the current provision of WM services in the UK and what is offered to patients in practice.

ATTITUDES TO OBESITY

Nike recently displayed an obese mannequin in its London store, wearing sportswear. On the 6th June, The Telegraph published an article by Tanya Bold, which caused a stir within the media.3 Titled Obese mannequins are selling women a dangerous lie, the article argued that 'the fat-acceptance movement, which says that any weight is healthy if it is yours, is no friend to women, even if it does seem to have found a friend in Nike. It may, instead, kill them, and that is rather worse than feeling sad'. Tanya Bold argues in the article that 'fat should not be a slur, but a warning'. Within newspapers, others (including Dr Nikki Stamp, cardiothoracic surgeon) have praised Nike for using an obese mannequin to showcase its clothing, arguing that it encourages people of all sizes to be more physically active, which cannot be a bad thing.4 A recent Cancer Research campaign aiming to increase awareness of the link between obesity and cancer,5 has also drawn criticism within the media, with many arguing that obesity should not be compared to smoking. Natasha Devon, writer and mental health activist, reported in the newspaper Metro, that 'Cancer Research’s obesity campaign isn’t just misguided - it’s dangerous', arguing that 'body shape and size is around 70% heritable - largely governed by genetics and hormones'. The article continues: 'These billboards - based on questionable assumptions - will serve only to make people ashamed of their bodies, which does nothing to improve their ability to

change their habits.'6 Although obesity is more complex than smoking, the link between obesity and cancer is well established, with more than 1 in 20 cancer cases found to be caused by excess weight.7 Like or loath this campaign, one thing is for sure; it has got people talking about obesity and cancer.

Obese people have been found to be stigmatised by healthcare professionals.

A study from 1987, which included 318 general practitioners, found a notable number of respondents held negative or stereotypical attitudes toward obese patients (ie, obese patients lack selfcontrol, are lazy and sad).8 This was mirrored in an American study from 2003, based upon a confidential and anonymous questionnaire sent to family practice physicians. Shockingly, of the 620 respondents, more than 50% viewed obese patients as awkward, unattractive, ugly and noncompliant.9 In regard to dietitians, a UK-based survey found overall neutral to positive attitudes towards overweight and obesity, but it did suggest that obesity was viewed less favourably to overweight.10

Alice Fletcher RD Countess of Chester NHS Foundation Trust (Community Dietitian) Alice has been a Registered Dietitian for five years, working within NHS community-based teams. She is passionate about evidence-based nutrition, cooking and dispelling diet myths.

REFERENCES Please visit the Subscriber zone at NHDmag.com

MORE THAN JUST CALORIES

Obesity is a very complex issue, as outlined extensively within the Foresight report of 2007.11 It is easy to get stuck on ‘calories in vs calories out’. Research has clearly demonstrated that some people have a greater genetic tendency to obesity than others.12 In experimental overfeeding between sets of identical twins, it has been shown that wide variation exists in the amount of weight gained, despite an www.NHDmag.com October 2019 - Issue 148

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This material is for healthcare professionals only

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References: 1. Dupont C et al. Br J Nutr 2012; 107:325–338. 2. Lothe L et al. Pediatrics 1989; 83:262–266. 3. Baldassarre ME et al. J Pediatr 2010; 156:397–401.

4. Nermes M et al. Clin Exp Allergy 2011; 41:370–377. 5. Canani RB et al. J Pediatr 2013; 163:771–777. 6. Canani RB et al. J Allergy Clin Immunol 2017; 139:1906–1913.

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COVER STORY Figure 1: The UK Obesity Care Pathway15

equivalent feeding of excess calories. Interestingly, contrary to what many may believe, discussing specific genetic predisposition to obesity (FTO gene) has been shown to make patients more determined to lose weight rather than less so.13,14 OVERVIEW OF UK WEIGHT MANAGEMENT (WM) SERVICES

While definitions vary locally, the obesity pathway consists of four tiers and, typically, Tier 1 covers universal services, Tier 2 covers lifestyle WM services, Tier 3 covers specialist multidisciplinary team WM services and Tier 4 covers bariatric surgery (see Figure 1).15 Tier 3 consists of a clinician-led multidisciplinary team of specialists, typically including a physician (consultant physician or GP with a specialist interest in obesity), specialist dietitian, specialist nurse, psychologist or psychiatrist and exercise therapist. Tier 3 forms the first link between community and specialist care, referring service users into Tier 4 services if appropriate. The same team members may be involved in Tiers 2-4.

PROVISION OF SERVICES

Public Health England has mapped the available Tier 2 and 3 services for adults across the UK,16 finding that the majority of Tier 2 services for adults were commissioned by local authorities and were delivered in community, leisure, or school settings. Two-thirds of services were multi-component and most were delivered over 12 weeks in predominantly group sessions. Most

respondents reported a minimum eligibility criteria of BMI>30, and the most popular referral routes were through GPs, practice nurses and/or other healthcare professionals and self-referral.

In the majority of reported services, average costs were less than, or equal to, ÂŁ100 per participant. However, the response rate for Tier 3 adult WM services was poor and the results are not reflective of all services available across England.16 The majority of respondents reported that Tier 3 WM services were commissioned by local authorities, and most followed up participants for 12 months or more. An observation based on respondent feedback was an inconsistency in the reporting of outcomes for WM services. This shows that outcome measures are ever more important in the commissioning of new services we need to show our worth!16 WEIGHT MANAGEMENT IN PRACTICE

Table 1 consists of practicalities that may not always be considered when setting up a new WM service. Before we even begin to assess patients, we need to make sure that they are able to access the clinic without untoward inconvenience and the clinic itself is as inviting as possible.

Assessment Assessment is the foundation of good obesity management and forms the essential first step in dietetic intervention. Without comprehensive understanding of what has contributed to the www.NHDmag.com October 2019 - Issue 148

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COVER STORY Table 1: Practical considerations when setting up a WM clinic17 Seating

Adequate numbers of large chairs with armrests, or regular chairs without arm rests and with sufficient space between chairs to allow easy movement.

Consultation seating arrangement that avoids the practitioner seated behind a desk.

Access

Consider the location and size of clinical rooms and the impact this may have on access for those with mobility issues.

Scales

Scales with a wide base that weigh more than 200kg located in a private area and consider how wheelchair users will be weighed.

Reading material

Magazines and literature with appropriate healthy lifestyle information and if possible positive images of larger people.

Temperature control

The use of portable fans in waiting areas and consultation rooms to maintain ambient temperature.

Telephones/interruption from other staff

Interruptions during consultations to be minimised where possible.

Fluids

Provision of drinking water where possible.

Table 2: Essential information to gather as part of dietetic assessment Essential information to gather as part of dietetic assessment ⇒ The story so far, what led up to the referral, this is an opportunity for the patient to tell their story and to feel heard and understood. ⇒ Understanding patients’ thoughts on referral.

⇒ Expectations of treatment – what they hope to gain from intervention. ⇒ Motivation to change lifestyle.

⇒ Weight history – including age of onset and family history of obesity.

⇒ Dieting history – what has been tried before. ⇒ Patients understanding of obesity and why their weight has increased. ⇒ Potential barriers to change.

⇒ Eating patterns – regular/erratic/binge eating/ only eating in private. ⇒ Current lifestyle: dietary intake and physical activity. ⇒ Support networks – family and friends.

⇒ Reward systems/strategies used to reinforce new behaviours.

The patients perceived importance of changing their behaviour and losing weight.

The patient’s confidence in their self to achieve weight loss through behaviour change.

Clinical information to gather: (This may be collected by the dietitian or the medical team.)

Ensure that the reasons for these tests are fully explained and consent is gained, as per NICE guidance.28 Measures to assess risk: - BMI - Waist circumference - Blood pressure - Fasting blood glucose/HbA1c - Fasting lipid profile - Thyroid function History: - Medical history (physical and psychological) including binge eating/other eating disorders - Medications/pharmacotherapy - Ethnicity - Family history of T2DM, CHD, stroke, endocrine disorders - History of gestational diabetes - History of infertility, PCOS, hirsutism - Contraception history - Smoking - Alcohol use Blood & Urine Tests: - Full blood count, folic acid, B12 - Vitamin D - LFT for non-alcoholic fatty liver disease (NASH) - HbA1c/glucose tolerance test if appropriate - Microalbuminuria if indicated - Hormone profile if indicated - Sleep studies, ECG or other tests as indicated

development of the patient’s obesity, how this impacts upon their life and the factors that influence changing eating and activity behaviours, it is impossible to tailor dietetic interventions to meet the needs of the individual.

Much of what has been written about assessment in obesity, focuses on the evaluation of medical risk and the classification of excess weight and body fat distribution through BMI and waist 14

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circumference measurements. Although these are clearly important areas to consider, they are only a small aspect of dietetic care and have little influence on understanding the patient’s current lifestyle and the approaches most likely to be helpful in altering eating and activity behaviours. It may be valuable for initial appointments to have more allocated time than subsequent ones, to allow all of this information (Table 2) to be gathered in detail.

COVER STORY Aims/ goals of intervention • The priority in WM should be to reduce risk factors for the service user, rather than to return them to an ‘ideal’ or healthy weight range.

• Very small degrees of weight loss produce health benefits, but significant changes result after a loss of 5-10%.18 • The aims should be led by the patient.

The opinion that when people lose large amounts of weight quickly, they will be less able to maintain their new weight in the longer term (and ‘slow and steady wins the race’) is outdated.19,20 • When setting goals it is important to make them SMART: specific, measurable, achievable, relevant and time specific.

• Clarifying the details of what has been agreed between the patient and dietitian by writing down the goal and how it is going to be achieved can be helpful in strengthening commitment, self-efficacy and understanding.

• Specifically working with patients on two or three goals at a time, waiting until these have been achieved before renegotiating on the next stages, can be important to gradually building up the patient’s confidence in their ability to achieve small behavioural goals.21,22 Frequency of follow up: • A recent review of behavioural WM programmes found that contact with a dietitian was one of the key predictors of success, and regular support from healthcare professionals is recognised as a central feature of obesity management.23,24 • The optimal frequency of contact remains unknown, with a recent review (2014) failing to find more frequent contact to predict more effective outcomes.25 • Behavioural WM programmes commonly have treatment durations of 8-12 sessions/ weeks, although debate continues about the potential value of extending beyond this minimum time.26,27 • In a recent study of primary care referrals to a UK commercial programme, an extended 52-week treatment produced greater initial

weight loss and clinical benefits together with less weight regain at two years compared with the brief intervention and the standard 12-week treatment.27 Despite the increased costs of delivering this longer programme, modelling suggested it would prove cost effective over the longer term.

Continuity of care – is this important?

• Services may employ several dietitians within the team; patients may not always be able to see the same person for each review.

• There is a lack of research exploring the importance of the same practitioner being involved in someone’s care in regard to obesity management outcomes.

• NICE guidance recommends continuity of care via meticulous record keeping, which is not suggestive of the same practitioner seeing the same patient consistently.28 • Qualitative research investigating the value of personal continuity in the GP relationship suggests that continuity may enhance trust,29 enablement30 and satisfaction on the part of the patient.31 Through good background knowledge of the patient, the GP can improve quality of care and their job satisfaction.32 • Given the above, it does appear pertinent to strive for consistency within the dietitian and patient pathway wherever possible.

DOES IT HAVE TO BE A DIETITIAN? UTILISING THE WIDER TEAM

Within the NHS Trust I work for, we utilise dietetic assistants (Band 4) to deliver our WM group education and support drop-in sessions, with the one-to-one assessments detailed above undertaken by specialist dietitians. Utilising the wider team may be particularly important during weight patient’s maintenance phase, which is vital for overall success. If capacity within the team is unable to support patients with weight maintenance, drawing on other healthcare professional services, appropriate commercial WM programmes, or encouraging more peer/ family support, may be required.

For further reading visit: www.NHDmag.com/references. www.NHDmag.com October 2019 - Issue 148

15

CONDITIONS & DISORDERS

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

EOSINOPHILIC OESOPHAGITIS Many may not have heard of eosinophilic oesophagitis (EO), but it is in fact becoming one of the most prevalent oesophageal diseases. It is the leading cause of dysphagia and food impaction in children and young adults, as well as affecting the adult population.1 As diagnosing EO has improved over recent years, more focus has been put on treatment options, including dietary management.

EO is the second most common cause of chronic oesophagitis after gastrooesophageal reflux disease (GORD), and occurs when there is damage to the oesophageal mucosa by esoinophils.2 Eosinophils are a type of white blood cells that make up part of our immune system, which have a beneficial role in defence and many other immune responses. However, eosinophils can also be damaging as part of the inflammatory process of allergic disease.3 Too many eosinophils result in chronic inflammation which can damage the mucosa lining the oesophagus.

Guidelines on management of EO define it as a local immune-mediated oesophageal disease, characterised clinically by symptoms related to oesophageal dysfunction and histologically by eosinophil-predominant inflammation.1 The cause of EO is not yet completely understood, but it can be triggered by eating certain foods, as EO is a distinct form of food allergy.1 It is thought to affect 400 per 100,000 people, more common in males2 and has a tendency to relapse-remit.

DIAGNOSIS

EO is diagnosed with the use of an endoscopy tube, which allows doctors to take a biopsy from the oesophagus lining to assess levels of eosinophils.

At least six biopsies from different locations in the oesophagus should be taken, and areas that show more than 15 eosinophils per high power field can be classed as EO. This threshold was set to help clinicians differentiate between EO and other oesophagus conditions such 16

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as GORD. Currently there are no noninvasive investigations with which to diagnose EO.1 SYMPTOMS

Dysphagia is a common symptom of EO and may be intermittent or continuous.

The severity of dysphagia can vary and, for some, it may result in a food bolus obstruction. In children, it is common to see failure to thrive, as well as regurgitation of foods. As a result of the dysphagia caused

by EO, people may develop habits such as excessive chewing of food, drinking lots of water at mealtimes and avoiding foods that could “get stuck” (eg, meats, or bread). In children, EO may result in ‘fussy eating’, or behavioural changes.2 TREATMENT

Due to the allergic nature of the disease, many pharmacological treatments are similar to those used to treat asthma, for example, the topical steroids budesonide or fluticasone. This treatment does, however, rely on a large amount of patient education and correct administration.2 Proton pump inhibitors (PPI) may be used to induce and help maintain remission of EO and, in particular, may help those patients who have GORD as well as EO. It is often found that pharmacological treatment alongside dietary management is the best treatment for EO. Oesophageal dilation may be used to provide some improvement in symptoms, but carries its own risks, such as oesophageal tears and perforation, and needs to be used in conjunction with dietary and/or drug treatment.2,4

CONDITIONS & DISORDERS ELIMINATION DIETS

As EO is an allergic-type immune response, it is common for patients with EO to have food allergy as a trigger for their symptoms, which is why elimination diets play a key role in identifying dietary triggers.

In children, the gold standard for assessing whether food allergy is associated with a patient’s EO symptoms is to commence an elemental enteral diet and gradually introduce foods into the diet. Enteral feeding may need to be administered via a tube, and should be followed for approximately six weeks before reintroducing foods.2 This regimen ensures that all food is substituted with a liquid formula composed of amino acids, carbohydrates, fats and minerals. The success rate of elemental diets is around 90%, but, in practice, they are rarely tolerated by patients.5 Barriers to elemental diets include the high cost, unpleasant taste and the social limitations that come with complying to a strict liquid-only diet.

A targeted elimination diet involves the removal of foods identified on allergy testing or patient history. Allergy testing typically involves skin prick or patch tests of a wide variety of foods.6 This approach is often deemed ‘simpler’ and, therefore, preferred by patients. However, it is not commonly used, as the success rate is <50%.5 Skin prick testing used in combination with atopy patch testing, may also be used as a guide to avoid specific foods in an elimination diet trial.

For adults, the most common dietary treatment is to use a six-food elimination diet, which is the preferred dietary therapy, given its relatively high success rate and acceptability by patients.5 This diet eliminates the six most common food allergens (eggs, wheat, soy, fish, dairy and peanuts) for six weeks. These foods are then reintroduced into the diet, one at a time, and the response assessed. A comprehensive meta-analysis of dietary interventions showed that this method achieved histological remission in approximately 72% of patients.5 FOLLOW UP

The role of a dietitian with understanding and expertise in elimination diets, food substitution and potential sources of cross-

contamination, is essential to help guide patients, particularly growing children, in helping maintain a nutritionally complete diet.

This requires knowledge and understanding of the potential nutrient deficiencies caused by the elimination of a specific food, as well as the appropriate substitution for that food. Guided advice is important to ensure patients are not unnecessarily over restricting. For example, if a patient is required to avoid cow’s milk, it is important they replace this with a calcium-rich alternative.

Once a patient has been identified as having a sensitivity to a particular food, or a trigger food has been identified, an experienced dietitian can help assess for and prevent contamination of the excluded foods. Cross-contamination can often occur at the levels of food manufacturing/ processing, preparation, cooking, and serving, and can easily transform an antigenfree food into an antigen-containing food.7 Comprehensive understanding and educating of food manufacturing can help identify potential contamination with potential trigger foods such as milk, soy, wheat, or nuts.

Cross-contamination during food preparation at home can be avoided by measures such as cleaning surfaces and utensils, as well as strict hand-washing between handling/cooking different foods. Educating patients on cooking skills and how to plan ahead for special occasions, can ensure that patients and their families feel confident in their food choices. Education on food labelling is also crucial, emphasising this should be checked with every purchase, as the manufacturing or processing frequently changes without clear notice to the consumer.7,8 SUMMARY

To conclude, EO is becoming an increasingly recognised condition and has links with dietary triggers. The symptoms may affect growth, behaviours and social outcomes.

MDT management is essential for identifying, diagnosing and treating the condition.

Elimination diets can help to identify specific dietary triggers and working with a specialised dietitian can help to achieve this safely, ensuring that patients avoid certain foods going forward. www.NHDmag.com October 2019 - Issue 148

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CONDITIONS & DISORDERS

DYSPHAGIA Every day we take swallowing for granted, but for those with dysphagia it can be stressful, unpleasant and unsafe.

Dysphagia is the medical term used to describe difficulty with swallowing.

Although it can differ in severity, dysphagia is estimated to affect approximately 11% of the UK’s population.1 Whatever the severity, without the correct management it can lead to difficulty in consuming enough food and/or drink, resulting in malnutrition or dehydration and/or can lead to aspiration, where the food or fluid goes into the airways, which can result in choking or pneumonia.

WHAT CAUSES DYSPHAGIA?

Dysphagia is usually caused by a medical condition, but it can also be a consequence of ageing due to loss of muscle mass or strength, or changes in the swallowing mechanism.2 The World Gastroenterology Global Guidelines3 estimate that dysphagia affects 40-70% of stroke patients, 60-80% of patients with neurodegenerative conditions, up to 13% of adults aged 65 and older and over 51% of institutionalised elderly patients, as well as 60-75% of patients who undergo radiotherapy for neck and head cancer.4 Dysphagia is also a key risk for people with dementia.5 According to the NHS, dysphagia signs include:6 • coughing or choking when eating or drinking; • bringing food back up, sometimes through the nose; • a sensation that food is stuck in your throat or chest; • persistent drooling of saliva; • being unable to chew food properly; • a ‘gurgly’ wet sounding voice during or after eating or drinking;

It is the responsibility of all those involved in the patient’s care to identify dysphagia. Identification should be followed by diagnosis, assessment and management by healthcare professionals with relevant skills and training, to confirm the presence and severity of dysphagia.7 MANAGING DYSPHAGIA

As a result of an impaired ability to consume adequate volumes of food and fluid, dysphagia patients also have an increased risk of aspiration, which can lead to aspiration pneumonia.

Up to 52% of people with dysphagia suffer from aspiration.8 Therefore, early detection and intervention involving a multidisciplinary team are both key.9,10 A patient’s swallow should be assessed by a healthcare professional, usually a Speech and Language Therapist, to determine the severity of the dysphagia. A patient may be able to eat and drink orally, but the texture of their food and thickness of their liquids may need to be modified, which is a key component in managing dysphagia.

Martha Jackson, Medical Nutrition Manager, 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

PUREED FOOD

A diet of puréed foods is recommended for patients who have difficulties with the oral preparatory phase of swallowing, who pocket food in the buccal recesses, or who have significant pharyngeal retention of chewed solid foods.11 When puréeing or liquidising foods for dysphagia patients, presentation and taste is important to make the food palatable and enjoyable. Using strong flavours and separating foods on the plate may help to encourage patients www.NHDmag.com October 2019 - Issue 148

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CONDITIONS & DISORDERS to eat orally and provide nutrition. Many care homes and hospitals rely on purĂŠeing in order to provide meals for dysphagia patients, but it can impact the nutritional content of foods with a reduction in energy, protein content, vitamins and fibre content during the process.12 MEDICAL FOODS

Medical foods may also be used for dysphagia patients under the supervision of a healthcare professional. These are specially formulated products to help with the management of dysphagia, including thickener powders to thicken the consistency of liquids, and prethickened products.

Thickening powder A thickening powder, available in gum or starch form, may be added to liquids in order to change the consistency. Thickened liquids are easier for patients with dysphagia as they travel more slowly down the throat, making them easier to control and less likely to cause aspiration. They can also be used to prepare texture modified foods, to help ensure food does not separate from liquid and to achieve an even consistency throughout.

Pre-thickened products Pre-thickened oral nutritional supplements (ONS) and puddings are available for individuals with dysphagia in a range of flavours. These products provide additional energy, protein, vitamins and minerals, and may be required for patients who are not able to get enough nutrition from standard food and drink alone.

When an ONS is required for a patient with dysphagia, a pre-thickened ONS should be used in preference to standard ONS which is thickened.

Tube feeding If dysphagia is very severe and it is deemed unsafe for a patient to consume food and drink orally, a feeding tube may be used. This could either be a nasogastric (NG) tube (usually indicated for a short duration), or a percutaneous endoscopic gastrostomy (PEG) tube which goes directly into the stomach.

Not only is it important to consider the individual needs of the patient when deciding which medical food to use, but

it is important that the patient is regularly monitored, so that their diet can be modified as necessary depending on the improvement or progression of their condition. Progression can vary greatly depending on the cause of dysphagia, with some patients experiencing a deteriorating swallow, for example a patient with a degenerative neurological condition, and other patients finding their dysphagia improves or completely resolves, for example a stroke patient.

Other management options for a patient with dysphagia include postural change and swallowing therapy.13 IDDSI In April 2019, the UK implemented the International Dysphagia Diet Standardisation Initiative (IDDSI) Framework14 to describe food textures and liquid thickness to improve patient safety.

The IDDSI Framework, which was adopted by the BDA and the Royal College of Speech and Language Therapists (RCSLT), consists of a continuum of eight levels, where drinks are measured from Levels 0-4 and foods from Levels 3-7. Detailed descriptors and simple testing methods accompany each level and can be used by people with dysphagia, caregivers, HCPs, food service or industry to confirm the level a food or fluid falls within.

Medical foods specifically designed for patients with dysphagia contain the IDDSI descriptors, including thickeners and prethickened ONS. Standard ONS, which may be used for patients with dysphagia but are not their primary target, are not labelled with the IDDSI descriptors.

CONCLUSION

It is fundamental that those at risk of dysphagia are identified and managed appropriately by a multidisciplinary team, in order to reduce the risk of malnutrition, dehydration and aspiration pneumonia. This includes modifying the diet to the appropriate IDDSI levels, allowing for the safe consumption of food and liquid. Medical foods should be used to enhance patient safety and ensure optimal nutrition. www.NHDmag.com October 2019 - Issue 148

21

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4. Mithal A et al. Osteoporos Int 2013;24(5):1555–1566. 5. Demling RH. Eplasty 2009;9:e9. 6. Malafarina V et al. Maturitas 2017;101:42–50. *Strength was measured by handgrip strength in a post hoc analysis of over 600 malnourished people with heart or lung diseases, age 65 or older. Ensure Plus Advance was consumed twice daily for 90 days. †As shown in a randomised control trial to investigate the effects of a specialised ONS on older women (≥ 65 years) who underwent surgery for hip fracture vs. standard postoperative nutrition. Muscle function was measured by hand grip strength. ‡Ensure Plus Advance was shown to preserve muscle mass in elderly patients after hip fracture surgery with rehabilitation when consumed twice a day for 30 days as compared to standard care.

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CLINICAL

UNDERNUTRITION I wrote on overnutrition in NHD a few months ago1a and its impact on public health. In this piece, I will flip the focus onto what is less prevalent in the UK, but remains a pressing issue, undernutrition – that is, clinically having a BMI under 20kg/m2, allowing for other factors such as age and morbidity.

Whilst the most recent data from the World Bank shows that only 3% of the population are undernourished,1b it still poses a public health issue affecting roughly 1.9 million people and costing around 19.6 billion pounds to the NHS in 2012,2 despite the fact that most of us in the developed world are lucky enough to have an abundance of food at our fingertips. Undernutrition is of particular concern in hospital patients, the elderly and those who live with certain eating disorders, namely anorexia nervosa; the eating disorder with the most strikingly elevated mortality risk.

CONTEXTUALISING UNDERNUTRITION IN THE DEVELOPED WORLD

When we think about hunger and starvation, the picture in our heads is likely to be set in a village in an African country, or amongst rubble and chaos in the Middle East. In developing countries, the reasons for undernutrition widely differ to the problems we have in the UK: war, civil unrest, famine, and extreme poverty are all factors to consider.

The ongoing Yemeni humanitarian crisis, often too difficult to fathom for anyone living comparatively idyllic existences in the UK, has yielded countless situations of chaos and desperation. One video account documents a young girl grinding up boiled leaves to be made into a paste, as her family’s only source of nutrition.4 Elsewhere, we see communities subsisting on cooked mud, because sacks of rice are too expensive.

The 2019 report from the Food and Agriculture Organisation of the United Nations (FAO) entitled The State of Food Security and Nutrition in the World, shows that, ‘820 million are undernourished, with undernourishment linked to economic downturn and instability’.5 Without a doubt, austerity, poverty and homelessness are issues in the UK that have worsened in the last decade, but our reasons for undernutrition differ in that they are rooted in deeper socioeconomic issues, such as neglect of the elderly, inadequate pension provisions and the hospital carousel amongst the elderly whereby admissions to hospital are an endless cycle. Furthermore, other instances of undernutrition tend to be caused by the anorexia nervosa eating disorder.

Moreover, due to undernutrition being less prevalent than overnutrition as far as the UK is concerned, cases of it often get overlooked.

Farihah Choudhury Masters Student, London School of Hygiene and Tropical Medicine Farihah is taking a MSc in Nutrition for Global Health.

She is interested in public health nutrition, in particular lifestyle disease, including obesity as a product of changing food environments, food sustainability and food culture & anthropology.

REFERENCES Please visit the Subscriber zone at NHDmag.com

UNDERNUTRITION IN THE ELDERLY

Undernutrition in the elderly is becoming an increasingly prevalent issue due to our ageing population. The major causes are ‘anorexia, cachexia, sarcopenia, dehydration, malabsorption and hypermetabolism’.6 Frailty is another consideration, characterised by at least three of the following criteria: • weight loss (>5kg per year) • self-reported exhaustion, weakness (fall in hand grip strength) • slow walking speed • low physical activity www.NHDmag.com October 2019 - Issue 148

23

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2014; 29:29–43. 5. Sioson MS, et al. 2018; 24:156–164.

CLINICAL Figure 1: Pathways from inadequate food access to multiple forms of malnutrition3

It is challenging to identify those at risk due to the difficulty of reaching and screening those who are most at risk, the lack of homogeneity of screening mechanisms and lack of consensus on what constitutes a malnourished individual.7 The effects of ageing present many obstacles for older individuals obtaining adequate nutrition. This list is extensive and includes: • swallowing problems due to previous morbidity or stroke; • decreased dental capacity due to dentures or periodontal disease; • frail skin; peripheral vascular disease; arthritis; • decreased capacity for use of hands; • malabsorption of nutrition; • diminished sensory capacity including taste changes and reduced appetite; and also more generally: • the effects of chronic disease and disability.

Socio-economically, austerity measures have disadvantaged retired pensioners, resulting in lower living allowances for food. Furthermore, loneliness in an ageing population, many of whom may be living by themselves, can result in a lower inclination to eat, due to the removal of the important social aspect of eating, ie, sharing breakfasts, dinners, a cup of tea and biscuits, etc (termed ‘social facilitation’).8

HOSPITAL ADMISSIONS

Perhaps the first time malnutrition in hospitals was considered in earnest, was with the publication of The King’s Fund report in 1992, which revealed that 66% of hospital patients were malnourished.9 Acute malnutrition can occur in individuals who have had sudden or short-term onset of disease. Morbidity prevents the individuals affected from accessing and enjoying food, so that patients admitted to hospital due to their morbidities are often malnourished upon their admission (thought to be between 25-40%).9 To make matters worse, during a hospital stay, patients have a tendency to eat poorly, regardless of whether their eating patterns have or have not already been affected by their illness, and it is thought that around 40% of hospital food is wasted,10 leading to patients only receiving 70% of their daily energy requirements.9 It is unsurprising then, that following the hospital stay, patients tend to return home undernourished, which affects their recovery, plus, the likelihood that they will be readmitted to hospital increases – and so begins the ‘undernutrition carousel’. Up to 70% of patients discharged from hospital weigh less than on admission.

Practical reasons for poor food intake during hospital stays include: www.NHDmag.com October 2019 - Issue 148

25

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CLINICAL • lack of staff to monitor and feed patients; • poor environment for eating (ie, noisy ward, inappropriate meal times); • lack of, or poor quality of snacks; • unappetising food; • food not prepared with patient in mind (ie’ choking risk, food that requires cutting).

Culturally, patients may receive food that they are not used to eating, or they may miss food they eat at home. Bulk food trolleys by patient beds seem to work best, as opposed to set mealtime provisions, yet are not always provided, whether this be down to convenience, cost or other factors.

EATING DISORDERS

Eating disorders are fairly rare in the general population; however, they are relatively common amongst young women.11 The overall incidence rate for anorexia nervosa has remained constant, but there has been an increase in prevalence amongst teenage girls and young women aged 15-19, who are seen as a high-risk group.11 It goes without saying that anorexia nervosa is the eating disorder with the greatest outwardly apparent expression of undernutrition.

Moreover, there are misperceptions and stigmas

attached to anorexia nervosa which do not help rationalise fully the complexity of the condition, and traditional approaches to encouraging food intake may not work, due to anorexia nervosa being a mental health condition.

THE FUTURE OF MALNUTRITION IN THE UK?

With an uncertain political climate affecting poverty and food security in the UK, as well as the already overstretched resources of the NHS, exacerbated by the clearly ageing population, all available evidence suggests that malnutrition in the UK is not a problem that can be brushed under the carpet. Public health initiatives are shifting to community approaches and community-led interventions,12 to maintain the nutritional needs of all members of the community, especially those who are at a higher risk.

Awareness of malnutrition in the developed world is increasing too; we had the first ever UK Malnutrition Awareness Week held in October 2018. The second will run from 14th October to 20th October this year, administered by BAPEN and the Malnutrition Task Force. Find out how you can get involved on BAPEN’s website: www.bapen.org.uk/malnutrition-undernutrition/ combating-malnutrition/malnutrition-awarenessweek.

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27

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The importance of palatability when choosing an extensively hydrolysed formula for the management of cow’s milk allergy in formula fed infants Cow’s milk allergy (CMA) is the most common food allergy in infants, affecting an estimated 1.3–2.9% of children in the UK.2,3 Expert consensus4 recommends extensively hydrolysed formulas (EHFs) as first line for formula-fed infants presenting with suspected mild-to-moderate IgE-mediated or non-IgEmediated CMA. Cow’s milk substitutes need to be both nutritionally adequate and well tolerated. In addition, the British Society for Allergy and Clinical Immunology (BSACI) recognise that palatability may be an important factor in formula choice, particularly in older infants, when managing CMA.5–7

Aptamil Pepti is the UK’s most palatable EHF20 In recently published research, the relative palatability of EHFs marketed in the UK was tested head-to-head by 100 healthcare professionals (51 dieticians and 49 General Practitioners). Overall, Aptamil Pepti was ranked as the most liked EHF on the UK market (Figure 1).20 Figure 1. Overall liking results (% of participants placing each sample in each rank position) Percentage participants

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Palatability is important because by the time infants are prescribed EHF their taste preferences may have already developed8

Poor palatability can sometimes be an issue for infants as research exploring the development of flavour preference in infancy seems to point to a ‘window of plasticity’ which begins to close at around 3.5 months of age.8 Unfamiliar flavours introduced following its closure may be at a heightened risk of rejection.12,15 Further, an audit of Primary Care data has shown that the mean age of presentation for infants with CMA is 3.2 months, with infants receiving a first prescription for a nutritional intervention at an average age of 5.4 months.16 Cow’s milk is a rich source of nutrients and optimal growth is particularly important in the early years when CMA occurs.17 Therefore, rejection of a cow’s milk substitute may become an issue clinically if infants first receive an EHF during a period in which the relative risk of rejection is high; inadequate intake potentially translating to a nutritional deficit.

For this reason, adequate consumption of a hypoallergenic formula, like EHF, is paramount to achieve nutritional requirements,18,19 and should continue until two years of age where CMA persists.5,6,9 For formula-fed infants with CMA, selecting the most suitable and acceptable EHF is crucial, and consideration should be given to palatability in order to ensure acceptability, and hence intake.

4 (Least liked)

Rank (1–4) Aptamil Pepti

Similac Alimentum

SMA Althera

Nutramigen LGG

Adapted from: Maslin K, et al. 2018.20

The superior palatability of Aptamil Pepti is likely due to the fact that it is a whey-based, lactose containing formula. Wheybased hydrolysates have been shown to have superior palatability compared with casein based hydrolysates.21 In addition, lactose, the primary carbohydrate in breastmilk, is believed to improve palatability, as well as helping to increase calcium absorption22 and positively affecting gut microbiota.23 The study also explored healthcare professionals’ beliefs around how palatability may impact infants and their families. The vast majority of participants agreed that better palatability would result in an increased chance of non-rejection (96%), more content families (92%) and infants (81%), and decreased wastage and healthcare costs (90%; Figure 2).20 Figure 2. HCP (n=100) perception of the impact of palatability, expressed as percentage agreement 100 Percentage agreement

In EHFs, the protein is broken down by hydrolysis in order to reduce its allergenicity.9 However, as a consequence, EHFs may be bitter in taste.10–14

3

(Most liked)

80 60 40

96

92

Increase the chance of nonrejection

Result in more content families

90

89

83

81

Decrease switch to other formula

Result in more content infants

20 0

Adapted from: Maslin K, et al. 2018.20

Decrease Increase wastage and compliance healthcare costs

Advertorial This information is intended for healthcare professional use only Breastfeeding is best for babies

Sensory attributes of Aptamil Pepti24

SUMMARY OF KEY POINTS

Knowledge of the attributes that affect palatability may aid in the understanding of which EHFs are relatively less likely to be rejected.

• CMA is the most common food allergy in infants2,3

Further work was undertaken to study the specific sensory aspects of Aptamil Pepti in comparison to the other available EHFs to help understand what made it the most palatable.

• EHFs are first-line formulas in most formula fed infants with CMA5–8,15,16

Sensory attributes including odour, flavour, basic tastes, texture, as well as mouthfeel and aftertaste, were studied.

• Bitter EHFs may be strongly rejected after 4 months of age12,15

Sensory notes such as ‘malty’ odour and flavour, ‘milky’ flavour, and ‘sweet’ were found to have a positive correlation with ‘liking’. Less desirable sensory characteristics include ‘saltiness’, ‘sourness’, ‘bitterness’, and ‘astringency’.24

• The mean age at first prescription of an EHF is 5.4 months16

The sensory attributes of Aptamil Pepti, scored the highest for all desirable notes (sweet, malty odour and flavour, and milky flavour), whilst also scoring the lowest for less desirable basic tastes (sour flavour, and bitter flavour and aftertaste; Figure 3).24

0–100 Assessment Scale

Casein-based

Casein-based

60 40

Whey-based

• BSACI guidelines recognise palatability as a key factor in EHF choice5–7 • A head-to-head study has shown Aptamil Pepti to be the UK’s most palatable EHF20

Figure 3. Key sample differences (mean scores)

80

• Poor palatability can lead to rejection, which could impact growth17,25

For further information, downloadable resources and e-learning, visit www.eln.nutricia.co.uk or contact our healthcare professional helpline on 0800 996 1234.

Whey-based

20 0 Milky

Malty

Veggy

Burnt cheese

Yeasty

Sweet

Salty

Sour

Bitter Astringent Fatty

Aptamil Pepti

Similac Alimentum

SMA Althera

Nutramigen LGG

Adapted from: Campden BRI. 2017.

24

IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cow’s milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is only suitable for babies over 6 months as part of a mixed diet.

References 1. Parrish CP, Kim H. CurrAllergyAsthma Rep 2018;18(8):41. 2.VenterC, et al. Allergy2008;63(3):354–359. 3. SchoemakerAA, et al. Allergy2015;70(8):963–972. 4.VenterC, et al. Clin Transl Allergy 2017;7(1):26. 5.VenterC, et al. Clin Transl Allergy 2013;3(1):23. 6. Luyt D, et al. Clin Exp Allergy 2014;44(5):642–672. 7. Walsh J, et al. BrJ Gen Pract 2014;64(618):48–49.

8. Mennella JA, et al. Am J Clin Nutr 2011;93(5):1019–1024. 9. Fiocchi A, et al. World Allergy Organ J 2010;3(4):57–161. 10. Pedrosa M, et al. J Investig Allergol Clin Immunol 2006;16(6):351–356. 11. Sausenthaler S, et al. Clin Nutr 2010;29(3):304–306. 12. Mennella JA, et al. Pediatrics 2004;113(4):840–845. 13. Miraglia Del Giudice M, et al.

Ital J Pediatr 2015;41(1):42.14. de Jong NW, et al. Ann Allergy Asthma Immunol 2014;113:227–238. 15. Mennella JA, Castor SM. Clin Nutr 2012;31(6):1022–1025. 16.

Sladkevicius E, et al. J Med Econ 2010;13(1):119–128. 17. Meyer R, et al. Clin Transl Allergy 2014;4(1):31. 18. Maslin K, et al. Clin Transl Allergy 2016;6:20. 19. Flammarion S, et al. Pediatr Allergy Immunol 2011;22(2):161–165. 20. Maslin K, et al. Pediatr Allergy Immunol 2018;29(8):857–862. 21. Venter C. Cow’s milk protein allergy and other food hypersensitivities in infants [Online]. https://www.jfhc.co.uk/cows-milk-protein-allergy-and-other-food-hypersensitivities-in-infants. Published: 24 November 2010.

Accessed: 16 August 2019. 22. Abrams SA, Griffin IJ, Davila PM. Am J Clin Nutr 2002;76(2):442–446. 23. Francavilla R, Calasso M, Calace L, et al. Pediatr Allergy Immunol 2012;23(5):420–427. 24. Campden BRI. Sensory Evaluation of EHFs following the Quantitative Descriptive Analysis (QDA®) approach. [S/REP/142065/1B]. 14th August 2017.

25. Vandenplas Y, et al. Eur J Pediatr 2014;173(9):1209–1216.

19-066. Date of prep: September 2019. © Danone Nutricia Early Life Nutrition 2019

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PUBLIC HEALTH

BACTERIA: THE GOOD, THE BAD AND THE UGLY More and more research is delving into the area of gut bacteria and its impact on health and disease, but whatâ&#x20AC;&#x2122;s good bacteria and whatâ&#x20AC;&#x2122;s bad and are probiotics the answer?

As humans are born, their individual gut microbiota develops and is affected by the birthing process and early life. For example, whether an infant is breastfed or formula-fed, or whether the mother has taken antibiotics during pregnancy or lactation, it has been shown to result in a different balance of microbiota in the infantâ&#x20AC;&#x2122;s gut.3,4 Furthermore, differences in gut microbiota have been identified between those born via the vaginal canal or by caesarean section, though arguably other factors may be driving these differences, as critically discussed

by Stinson et al.5 A multicentre European study by Fellani et al, found that breastfed infants had significantly higher proportions of Bifidobacteria (40.7% vs 29.2%, P<0.001) than formula-fed infants.6 Additionally, this study found that country of origin effected gut microbiota balance post weaning: infants from northern European countries had a higher proportion of Bifidobacteria, whereas infants from southern European countries had higher proportions of Bacteroides and Lactobacilli.6 It could be considered that the types of foods an infant is weaned on and their overall dietary intake will help determine which bacteria dominate for life. It is the foods eaten long term, along with other factors, such as environmental temperature and individual physiology,2 that play key roles in gut microbiota development.

Once developed, the microbiota of an individual is quite stable for life. However, there are some factors that can lead to gut flora changes, for

example, antibiotic use, ageing, changes in diet such as drastic calorie changes, or altering macronutrient balance. Also, high-fibre diets are associated with increased diversity of microbiota.7 TYPES OF GUT BACTERIA

Numerous types have been identified in the human gut. However, the main two phyla are the Bacteroidetes and the Firmicutes.2 These two phyla differ in the efficiency of their metabolism. For example, a study by Turnbaugh et al showed that obese individuals and mice with a higher proportion of Firmicutes bacteria had a higher capacity to harvest energy.8 The study also showed that when the microbiota was transplanted from obese mice to germ-free mice, they rapidly gained fat mass, despite a decrease in food consumption. In another study, the abundance of Bacteroidetes was shown to increase as obese individuals lost weight on different low-calorie diets with a correlation that was significant.9 With obesity being a challenging and multifaceted health concern, it is important to address gut microbiota, as it may be a contributing factor, together with genetics, diet and lifestyle.

Throughout the human gastrointestinal tract, the microbiota increases in both number and diversity, being affected by factors such as pH, transit time and nutrient availability.10 As the colon has the slowest transit time, a favourable pH and has plentiful available nutrients, the collection of microbiota is most varied and populated here.

The intestinal microbiota has several beneficial roles:

Priya Tew Freelance Dietitian, Dietitian UK Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, consultancy for food companies and private patient work.

Naomi Leppitt Dietitian Naomi is newly qualified, working as a Community Dietitian in Windsor.

REFERENCES Please visit the Subscriber zone at NHDmag.com

www.NHDmag.com October 2019 - Issue 148

31

PUBLIC HEALTH Table 1. Types of intestinal microbiota found throughout the human gastrointestinal tract.10 Intestinal Microbiota Number Lactobacillus Streptococcus Staphylococcus Enterobacteriaceae Yeasts Clostridium Bifidobacterium Fusobacterium Bacteroides Eubacterium Peptostreptococcus

Stomach <103 CFU/ml ✓ ✓ ✓ ✓ ✓

Duodenum & Jejunum 102-105 CFU/ml ✓ ✓ ✓ ✓ ✓

• Metabolism: – Synthesis of vitamin K*, some water-soluble vitamins and all essential and non-essential amino acids.2 – Absorption of nutrients: - calcium, magnesium, iron; - lipid metabolism through bile acid metabolism.11 – Fermenting non-digestible carbohydrates, such as dietary fibre, resistant starches, cellulose, pectins, gums, unabsorbed sugars and alcohols:2 - Energy and other substrates can then be harvested and used.

- Short-chain fatty acids are produced from the digestion of carbohydrate: butyrate has tumour suppressing activity,12

and this reduces levels of colonic cancer. *Escherichia coli and Salmonella enterica biosynthesise menaquinone-vitamin K2, which is an essential nutrient that humans and other mammals cannot synthesise themselves.13 • Immunomodulation: – Effects composition of the gut-associated lymphoid tissue (GALT): - Intestinal epithelial cells can avoid patho genic impact by signalling receptors of the innate immune system to bind to bacteria associated substances.2 In response, the body protects itself from pathogenic microbes.

– Defence against harmful microbes by competing for binding sites on the intestinal wall, competing for available nutrients and by producing antimicrobial compounds.2 32

www.NHDmag.com October 2019 - Issue 148

Ileum & Caecum

Colon

103-109 CFU/ml ✓ ✓ ✓ ✓ ✓ ✓

1010-1012 CFU/ml ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

THE BAD AND THE UGLY

Sufferers of IBS will be well aware of the side effects of certain bacteria. Some fermentable carbohydrates are poorly absorbed by the intestinal system. Upon ingestion of these FODMAPS, there is osmotic action, where fluid is drawn into the lumen of the colon,14 and they are also fermented by bacteria in the colon, producing methane and or hydrogen gas.15 Together, these produce the commonly experienced symptoms of bloating, flatulence, abdominal pain and loose stools.

Evidence shows that disturbances to the microbiota may contribute towards IBS developing, with faecal analysis of individuals with IBS showing significantly lower amounts of Lactobacilli and Bifidobacteria and increased proinflammatory Enterobacteriaceae.16 A meta-analysis found the Bifidobacteria, Lactobacillus, Escherichia coli and Enterobacter were significantly altered between IBS patients and healthy controls.17 When the gut microbiota is imbalanced, research is revealing links with disease states.

Examples include inflammatory bowel disease and conditions related to systemic inflammation such as Type 2 diabetes and obesity, as well as a tendency towards allergy.2 Food that isn’t sanitary can severely disrupt the composition of the microbiota, or cause small intestine bacterial overgrowth (SIBO), leading to chronic malabsorption of nutrients, chronic inflammation and increased intestinal permeability. This can then lead to systemic inflammation, malnutrition, faltering growth and stunting.18

PUBLIC HEALTH Allergies may be a result of altered microbiota composition in early life, through the hypothesis that this stimulates the immune system and ‘trains’ it to respond to antigens.

But this happens disproportionately, leading to allergic reactions.2 Cardiovascular health is also related to microbiota, as described in a review by Tang et al: atherosclerotic plaques contain bacterial DNA the same as that found in the gut; metabolites generated by gut microbiota have been found to be a factor in the development of cardiovascular disease development.

Microbiota may also have a role in blood pressure regulation; gut permeability results in bacterial translocation and systemic inflammation, which has been identified in patients with heart failure.19 WHAT ARE PROBIOTICS?

The term probiotic was first coined in the 60s and it was defined by the FAO/WHO and later updated as ‘live microorganisms that, when administered in adequate amounts, confer a health benefit on the host.20,21 Probiotics are classified according to their strain, as the effects of a particular bacteria are strain-specific and not always the same across all bacteria of the same species. However, benefit can be attributed to a whole class, such as Bifidobacterium or Lactobacillus.21 In addition, a probiotic must be seen, in controlled studies, to have benefits to health.

Identifying and quantifying the health benefit to the host is a challenging area to research, due to the effects of probiotics being numerous and multifactorial and often through multiple mechanisms and sites of action.

Probiotics are differentiated from gut bacteria by the fact they’ve been isolated and have credible health effects.

Fermented foods are not considered probiotics, as though they may have health promoting effects, each batch may have different bacteria and in different amounts.

Also, though evidence is expanding into the area of the health benefits of faecal transplants, these are not classified as probiotics as the bacteria differs from donor to donor.

HOW CAN THEY INFLUENCE THE GUT?

The mechanisms of probiotics are complex and depend on the strain and the site at which they act. For example, consensus research has shown that probiotics may compete with pathogens for essential nutrients, or for binding sites on the intestinal lining, they may produce antimicrobial substances, or short-chain fatty acids, improve transit, stabilise the intestinal barrier, or have roles in immunomodulation, or mucin production.10 The unique balance of microbiota in any individual is relatively stable and resistant to change, generally returning to normal after disturbances such as antibiotics, immunosuppression and other factors.10 During antibiotic therapy, the benefit of probiotics may have greater influence.10 The World Gastroenterology Organisation reports the guidelines for clinical recommendations based on evidence for probiotic use in different diseases.22 For patients with IBS that choose to try probiotics, NICE guidelines advise trying them for a minimum of four weeks, while monitoring the effects, at the dose recommended by the manufacturer.23 This is to test whether that probiotic beneficially alters microbiota composition resulting in alleviated symptoms.

The BDA advise that probiotics may be unlikely to provide substantial benefits.24 Probiotics using lactic acid bacteria are considered safe as they have a long-term history of safe use in food.10 HOW CAN I PICK AN APPROPRIATE PROBIOTIC?

The International Scientific Association for Pre and Probiotics (ISAPP) recommends asking the following questions: Does it correlate to the dose used in studies? Does it provide an effective dose? Is it safe? What are the known health benefits associated with that strain? Does it provide the benefit being sought? Also, check the label. Does it give the full name of the strain; the number of live organisms in each dose (Colony forming units, CFU); the suggested dose; storage information and best before date; company information.

Note: If an individual has acute pancreatitis of multiorgan failure, lactic acid is not advised.

Probiotics and live yoghurts are also not advised for those on neutropenic diets. www.NHDmag.com October 2019 - Issue 148

33

THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS USE ONLY

BREAST MILK IS BEST FOR PRETERM INFANTS When breast milk isn’t available, nutriprem is nutritionally closer than any other preterm formula* Preterm infants have very high nutrient requirements and face a significant risk of growth failure, developmental delay, necrotising enterocolitis (NEC) and late-onset sepsis.1 Breast milk is best for preterm infants and offers an array of benefits including decreased rates of these conditions and improved neurodevelopmental outcomes.1 However, when breast milk is not available or in limited supply, a preterm formula that is nutritionally closer to breast milk offers the best alternative.2

Whey and casein proteins are important for supporting optimum development in preterm infants Breast milk contains a mixture of whey and casein proteins in varying proportions, from around 20% casein at birth, rapidly increasing to over 40%.3 Whey and casein proteins have individual specific functions, including digestion, immune function and mineral absorption.3 While the unique benefits of breast milk proteins can not be replicated in a formula, only nutriprem provides a protein composition which mirrors that of breast milk by including both whey and casein proteins in appropriate ratios.

Intact proteins in breast milk support gastrointestinal development Over 99% of proteins in breast milk are intact.4 Experts believe that intact protein may have a role in gut maturation, as the intact proteins in breast milk are digested into bioactive peptides which support the development of the gut.5,6 Hydrolysed

and partially hydrolysed formulas are available and have a role in supporting some preterm infants who fail to tolerate an intact protein formula.

However, these formulas may prevent the formation of bioactive peptides that occurs during the digestion of intact proteins.6,7

Lactose is a key energy source for breastfed infants Lactose, the main carbohydrate and key energy source for breastfed preterm infants, enhances calcium absorption and may provide a prebiotic effect.8-10 Lactose therefore is the predominant carbohydrate in nutriprem. Maltodextrin is an alternative polysaccharide carbohydrate source often used in preterm formula, but has been linked to reduced stool frequency and increased stool hardness and therefore may not be appropriate for use as the main carbohydrate source for preterm infants.11

Phospholipid-bound LCPs help create a fat profile closer to breast milk Fatty acids are typically bound to triglycerides, but in breast milk up to 20% of the long-chain polyunsaturated fatty acids (LCPs) are instead bound to phospholipids, which improves their absorption in preterm infants.12–14 Only nutriprem preterm formulas contain 15% of the LCPs in phospholipid bound form. Together with betapalmitate sourced from natural milk fat and 10%* of fat from medium chain triglycerides (MCT), the fat composition of nutriprem preterm formulas are closer to breast milk than any other preterm formula in the UK.15–20

Prebiotic oligosaccharides (OS) significantly impact gut microbiota and GI health Breast milk is incredibly rich in prebiotic OS with approximately 200 prebiotic OS identified to date,21 which encourage the growth of beneficial bacteria (such as bifidobacteria) and inhibits growth of potentially harmful bacteria in the gut.21 Nutriprem preterm formulas* contain a blend of 9:1 short-chain GOS:long chain FOS, which mimics the prebiotic effect of the oligosaccharides found in breast milk.

Nutricia’s GOS/FOS blend has been proven to help promote a microbiota composition, stool frequency and stool consistency closer to breastfed infants.11,22,23

The only nutritionally complete post discharge formula with a composition closest to breast milk Experts recommend that infants at risk of long-term growth failure require a specialist post discharge formula with increased protein, minerals and trace elements.24 Only nutriprem post discharge formula offers a nutritionally closer to breast milk composition, prebiotic oligosaccharides and sufficient iron to meet their daily requirements up to 6 months corrected age.2,25**

NUTRIPREM IS NUTRITIONALLY CLOSER TO BREAST MILK THAN ANY OTHER PRETERM FORMULA IN THE UK.*

Composition

Preterm breast milk

nutriprem 1

Gold Prem 128

nutriprem 2

Protein ratio

60:40 whey:casein3

60:40 whey:casein

100% whey

60:40 whey:casein

100% whey

Protein type

Over 99.9% intact protein4

100% intact protein

100% partially hydrolysed protein

100% intact protein

100% partially hydrolysed protein

Lactose

Lactose

Maltodextrin

Lactose

Lactose

7.3g/100ml26

5g/100ml

3.7g/100ml

5.9g/100ml

5.3g/100ml

Main Carbohydrate Lactose level Medium chain triglycerides (MCT) Phospholipid bound LCPs Betapalmitate source Prebiotic Oligosaccharides Iron

7-17%

15–18

10%

39.5%

Gold Prem 228

10%

~6%

Up to 20% of LCPs12,14

15% of LCPs

0% of LCPs

15% of LCPs

0% of LCPs

Naturally occurring

Natural milk fat

Structured vegetable fat

Natural milk fat

Structured vegetable fat

0.5-1.1g per 100ml27

0.8g per 100ml

No prebiotic OS

0.8g per 100ml

No prebiotic OS

1.2mg/100ml

0.8mg/100ml (will not meet 2-3mg/kg in typically consumed volumes)

Guidelines recommend 2-3mg/kg up to six months corrected age2,25

Correct as of May 2019. *nutriprem 1 and nutriprem 2 only **SMA Gold Prem 2 contains 0.8mg/100ml iron which will not meet the recommended daily iron requirements of preterm and low birth weight infants up to 6 months corrected age

NOT nutritionally complete**

IMPORTANT NOTICE: Breast milk is best for babies. Nutriprem human milk fortifier, nutriprem protein supplement, hydrolysed nutriprem, nutriprem 1 and 2 are foods for special medical purposes for the dietary management of preterm and low birthweight infants. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed nutriprem, nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low birthweight infants.

References: 1. Underwood MA. Pediatr Clin North Am. 2013;60(1):189–207. 2. Agostoni C et al. J Pediatr Gastroenterol Nutr. 2010;50(1):85–91.

3. Lönnerdal B. Am J Clin Nutr. 2003;77(6):1537S–1543S. 4. Lönnerdal B. Protein in Neonatal and Infant Nutrition: Recent Updates. 2016;86:97–107.

5. Senterre T., Rigo J. Nestle Nutri Inst Workshop Serv. 2016;86:39–49. 6. Vandenplas Y et al. J Pediatr Gastroenterol Nutr. 2016;62(1):22–35.

7. Wada Y and Lönnerdal B. Peptides. 2015;73:101–105. 8. Abrams SA, Griffin IJ, Devila PM. Am J Clin Nutr. 2002;76:442–6. 9. Schaafsma G. Inter Dairy J. 2008;18(5):458–465. 10. Ziegler E et al. J Pediatr Gastroenterol Nutri. 1983;2(2):288–94. 11. Mihatsch W et al. Acta Paediatr. 2006;95(7):843–8. 12. Bitman J et al. Am J Clin Nutr. 1984;40(5):1103–19. 13. Carnielli V et al. Am J Clin Nutr. 1998;67(1):97–103. 14. Harzer G et al. AM J Clin Nutr. 1983;37(4):612–21.

15. Genzel-Boroviczény O et al. Eur J Pediatr. 1997;156(2):142–7. 16. Boker S et al. Ann Nutr Metab. 2007;51(6):550–6. 17. Ehrenkranz R et al. J Pediatr Gastroenterol Nutr. 1984;3(5):755–8. 18. Bitman J et al. Am J Clin Nutri. 1983;38(2):300–12. 19. Innis S et al. Lipids. 1994;29(8):541–5. 20. Ballard O et al. Pediatr Clin North Am. 2013;60(1):49–74. 21. Marcobal A., Sonnenburg J. Clin Microbiol Infect. 2012;18, Suppl 4:12–5. 22. Boehm G et al. Arch Dis Child Fetal Neonatal Ed. 2002;86(3):F178–F181. 23. Knol J et al. Acta Paediatr. 2005;94(449):31–3. 24. Aggett P et al. J Pediatr Gastroenterol Nutr.

2006;42(5):596–603. 25. Domellöf M. World Rev Nutr Diet. 2014;110:121–39. 26. Koletzko B et al. Nutritional Care of Preterm Infants. Karger. 2014.

27. Kunz C et al. J Pediatr Gastroenterol Nutr. 2017;64(5):789–798. 28. SMA Gold Prem 1 and Gold Prem 2 datacards. Accessed May 2019. https://www.smahcp.co.uk/sites/site.prod1.smahcp.co.uk/files/2018-12/ZTC3149%20SMA%20Preterm%20Datacard%20FINAL_0.pdf

Healthcare professional helpline 0800 996 1234 eln.nutricia.co.uk

@NutriciaELNHCP

19-035. August 2019

COMMUNITY

BREASTFEEDING: OUR DUTY AS HCPS TO GIVE THE BALANCED PICTURE In the UK, breastfeeding rates are lower than most of Europe. Whilst almost three quarters of women started breastfeeding at birth,1 only a third were still breastfeeding at six months.2 Breastfeeding can be a highly emotive topic. Mums want to give their babies the best start in life and nutritionally speaking we know that breastmilk is the best option. “Breast is best”, not only for the infant but for the mother too: breastmilk provides the infant with protective factors that resist gastrointestinal, respiratory and ear infections.3 Breastfeeding is also associated with higher scores on intelligence tests in later life3 and it is also shown to protect the mother from breast cancer, improve birth spacing and it may even reduce ovarian cancer and Type 2 diabetes.3 Not only does breast milk supply nutrients, but the act of breastfeeding is calming for the baby and supports their mouth and jaw development.4 RECOMMENDATIONS

It is recommended that infants should be exclusively breastfed for the first six months of life, as breastmilk supplies all the nutrients the infant requires to develop and grow.4 Colostrum, the milk produced in the first few days after giving birth, is a concentrated source of nutrients for those early days when baby cannot take much in their tummy.

Beyond six months, solids should be introduced to support the infant’s additional requirements and breastfeeding should be continued up to two years or beyond.4 It is tricky to make recommendations at this stage, as each mother and baby are variable in when and how much they wean, so some intuition and adjustment is required.

Mothers need to be in positive energy balance whilst breastfeeding, to account for meeting her own needs, plus the needs of the infant, as well as taking into consideration the extra energy that the body needs to produce breastmilk, and how efficient mum is at converting what she eats into breastmilk.

Priya Tew Freelance Dietitian, Dietitian UK Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, consultancy for food companies and private patient work.

NUTRIENT DEFICIENCIES

It is understandable that a mother may be concerned about providing enough nutrition for her baby.

However, it should be reassuring that milk composition is very resistant to marginal deficiencies in maternal diet and micronutrient deficiencies are rare in breastfed infants, except if the mother is severely depleted pre/postnatally.

Table 1 overleaf provides more detail on specific recommendations for maternal diets to ensure breastmilk volume and composition is adequate.

Every baby is unique and whilst breastfeeding may come quite naturally to some mums and babies, to others it can bring its own set of complications and problems. There is the potential to over-simplify breastfeeding, leaving mums who find breastfeeding difficult, feeling that they are failing their baby. As healthcare professionals, we have a role to encourage and support breastfeeding, but also need to be aware of when to allow mums to know it is ok to stop.

Naomi Leppitt Dietitian Naomi is newly qualified, working as a Community Dietitian in Windsor.

REFERENCES Please visit the Subscriber zone at NHDmag.com

BREASTFEEDING SUPPORT

Breastfeeding support groups and counsellors can play a key role in www.NHDmag.com October 2019 - Issue 148

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Supporting Mums to Breastfeed Lansinoh® – a company founded by a mother with a passion to support & encourage breastfeeding – have a range of breastfeeding products to assist new mums in providing their babies with the best start in life.

Here are three Lansinoh products that can help overcome common breastfeeding challenges you may be asked about by mothers in your care.

HPA® Lanolin Lanolin creates a temporary barrier to promote a moist wound healing environment*. Lansinoh’s HPA® Lanolin soothes and protect sore and cracked nipples, helping to replenish skin back to its natural state. 100% natural so there’s no need to remove before breastfeeding.

It’s is also the only lanolin product to have received the British Allergy Foundation Seal of Approval.

Thera°Pearl® 3-in-1 Breast Therapy The Lansinoh Thera°Pearl® Breast Therapy Pack can be used hot or cold to help relieve mastitis, engorged breasts and encourage let down.

Flexible and reusable, Thera°Pearl® 3-in-1 Breast Therapy pack has soft covers that can be slipped comfortably inside the bra to relieve any discomfort caused by some conditions associated with breastfeeding.

This product can also be used with a breast pump.

Contact Nipple Shields Lansinoh Contact Nipple Shields can be used as an effective, short term tool to support mums to breastfeed, under the encouragement, guidance and appropriate advice of a healthcare professional.

The shields can be used to help with flat or inverted nipples, tongue and/or lip tie, and over-active let-down. They can also be used for feeding a premature, small or ill baby.

You can discover more about helping mums to breastfeed at: www.lansinoh.co.uk/professional *Field CK, Kerstein MD. Overview of wound healing in a moist environment Am J Surg. 1994; 167 (1):S2-S6

COMMUNITY Table 1: Breastfeeding estimated nutrient requirements Energy Protein Fat

Vitamins

Minerals

+1.38 MJ/day 325-425kcal/day +11g/d +200mg/d DHA 2 portions fish week, 1 of which should be oily Vitamin C: +30mg/d Vitamin A: +350µg RE/d Thiamin: +0.2mg/d Vitamin D: 10µg/d Riboflavin: +0.5mg/d Vitamin E: >3mg/d Niacin: +2mg/d folate: +60µg/d Vitamin B12: +0.5µg/d Iron: 14.8mg/d Calcium: 1250mg/d Iodine: 250µg/d

supporting women to continue breastfeeding and to normalise any problems that arise. Our breasts are not a body part we talk about and show each other on a regular basis, which can mean some mums will find the act of talking about nipple shapes, or breastfeeding in public, intimidating. Having a supportive environment where this is normalised can make the transition to motherhood easier. So, do advise mums to look for local groups, such as the NCT breastfeeding cafes and La Leche League groups.

COMMON ISSUES

Baby’s weight gain Whilst it can be normal for a baby to lose a little weight in the first few days post-birth, it can also be a sign that breastfeeding is not being well initiated. Colostrum is produced from midpregnancy and can actually be harvested by hand in the last few weeks of pregnancy, then stored in the freezer for use in those first few weeks post-birth. Milk production starts to be seen two to three days post-birth for most mums.

Mastitis/blocked ducts This is when a milk duct becomes blocked. A lump can be felt and the breast may be swollen, hot, red and tender to touch. The mum may have a temperature and flu-like symptoms. Having this on top of a newborn baby to look after is, therefore, exhausting and it is important that the mum gets some help. Feeding is usually painful. However, it is also important to carry on feeding. Pumping or hand expressing milk can help to clear the duct along with breast massage. Refer mums to their GP/health visitor as antibiotics may also be needed.

Nipple pain, soreness and bleeding Using nipple cream and nipple shields can help with this. These issues are not well talked about and some mums may feel they need to stop breastfeeding as it is uncomfortable. Normalising the fact that breastfeeding is a new skill for baby, for mum (and for breasts!), can help mums understand that it can take time to master.

Cluster feeding On some days, it can feel as though baby is constantly feeding. This can be due to a developmental leap, teething, sickness, for comfort, or due to a growth spurt. Feeding baby on demand can be hard work, but babies really do know best!

If a mum is really struggling with breastfeeding, then it is part of a healthcare professional’s role to help counsel them into seeing what is right for baby and themselves at that point. Combination feeding is an option, where baby takes some milk via the breast and some formula too. Pumping milk to store for a bottle feed is another option. Of course, there is also the option of fully formula feeding babies and some babies may have to be formula fed from birth. It is key that mums feel supported to make their decisions and are educated about all the options.

Useful resources

NCT: www.nct.org.uk Kelly mom: www.kellymom.com La Leche League: www.llli.org www.NHDmag.com October 2019 - Issue 148

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

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Neocate Syneo is a Food for Special Medical Purposes for the dietary management of Cow’s Milk Allergy, Multiple Food Protein Allergies and other conditions where an amino acid based formula is recommended. It must be used under medical supervision after consideration of all feeding options, including breastfeeding. †Product can be provided to patients upon the request of a Healthcare Professional. They are intended for the purpose of professional evaluation only. *Accurate at time of publication, October 2019 Probiotic Bifidobacterium breve M-16V and prebiotic scFOS/lcFOS blend CMA: Cow’s Milk Allergy AAF: Amino Acid-based Formula References: 1. Candy et al. Pediatr Research. 2018;83(3):677-686 2. Burks W. et al. Pediatr Allergy Immunol 2015;26:316-322 3. De Boissieu D. et al. J Pediatr 1997; 131(5):744-747 4. Vanderhoof JA. et al. J Pediatr 1997; 131 (5):741-744 5. Fox et al. Clin Tranl Allergy. 2019;9:5 Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ

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

PAEDIATRIC

WEANING AN INFANT WITH COW’S MILK PROTEIN ALLERGY (CMPA) CMPA is the most common food allergy in babies and young children and the management of CMPA is an ever-evolving landscape. Part 1 of this two-part article takes a look at how CMPA is diagnosed and managed during weaning.

CMPA can be defined as a reproducible adverse reaction of an immunological nature induced by cow’s milk protein.

CMPA can be classified into IgEmediated immediate-onset, or non-IgEmediated delayed-onset, or a mixed picture, depending on the timing of the onset of symptoms and the organs involved.1 The prevalence of CMPA varies between 1.8% and 7.5% of babies during the first year of life, depending on the type of feeding the infant is receiving: CMPA is more common in formulafed or mixed-fed infants (7%) than in breastfed infants (0.5%).2,3 CMPA most often presents with symptoms within the first three to six months of life and rarely presents after 12 months of age.

The focus of CMPA management has shifted over the past 10 years from one of strict avoidance of the known food allergens and provision of suitable alternatives, to a balancing act between avoiding allergens and at the same time promoting the acquisition of oral tolerance.4 WHEN SHOULD COW’S MILK PROTEIN ALLERGY (CMPA) BE SUSPECTED?

CMPA should be suspected in infants or children who have one or more of the signs and symptoms described in Table 1 opposite.3 PROGNOSIS

The outlook for children with CMPA is very positive, with most children growing out of their CMPA, although the age at which this occurs is highly variable. Approximately 75% of children

with CMPA will grow out of their allergy by three years of age and 90% will have outgrown it by six years of age. CMPA will persist until adulthood in a small percentage of individuals.

The ESPGHAN guidelines5 recommend that children be re-evaluated every 6-12 months to assess tolerance to cow’s milk protein. In 2015, Lifschitz et al2 reported that, overall, children with non-IgEmediated CMPA have a better chance of outgrowing their allergy, whereas children with IgE-mediated CMPA with high levels of milk-specific IgE antibodies, multiple food allergies and/ or concomitant asthma and allergic rhinitis, had a higher risk of CMPA persisting for longer.2,5

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.

HOW IS CMPA DIAGNOSED?

Early and reliable diagnosis of CMPA is very important, so that the appropriate dietary restrictions can be initiated where CMPA is confirmed, or avoided where the diagnosis has been refuted.1 When there is a suspicion of CMPA in an infant, an allergy-focused clinical history, tailored to the presenting symptoms, is the first step in assessing the child.3 An ‘allergy-focused diet history’ tool has been developed by Isabel Skypala and Carina Venter to help guide the correct and accurate diagnosis of CMPA.6 The European Academy of Allergy and Clinical Immunology (EAACI) guidelines on food allergy suggest that the allergy-focused history is fundamental to the establishment of a diagnosis and the mechanisms and food triggers involved.7

REFERENCES Please visit the Subscriber zone at NHDmag.com

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PAEDIATRIC Table 1: Signs and symptoms of CMPA IgE-mediated CMPA

Non-IgE-mediated CMPA Speed of onset of symptoms

Acute and a rapid onset (up to two hours after ingestion) Skin reactions Pruritus (itching) Erythema (redness) Acute urticarial – localised or generalised Acute angioedema – most commonly of the lips, face and around the eyes

Non-acute and generally delayed (manifest up to 48 hours after ingestion) Pruritus Erythema Atopic eczema

Gastrointestinal symptoms Angioedema of the lips, tongue and palate Oral pruritus Nausea Colicky abdominal pain Vomiting Diarrhoea

Gastro-oesophageal reflux disease Loose or frequent stools Blood and/or mucus in stools Abdominal pain Infantile colic Food refusal or aversion Constipation Perianal redness Pallor and tiredness Faltering growth in conjunction with at least one or more gastrointestinal symptoms above (with or without significant atopic eczema)

Respiratory symptoms (usually combined with one or more of the above signs and symptoms) Upper respiratory tract symptoms (nasal itching, sneezing, rhinorrhoea, or congestion, with or without conjunctivitis) Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath)

Asthma

Other Signs or symptoms of anaphylaxis or other systemic allergic reactions

The ‘Management of Allergy in Primary Care’, or MAP guideline has been developed to help clinicians and dietitians with the diagnosis of infants with suspected CMPA.8 This guideline was developed predominantly to help diagnose infants with suspected non-IgE-mediated CMPA, but also talks about IgE-mediated CMPA. This has recently been updated to the new international iMAP guidelines.9 There has also been an recent update to the Milk Allergy in Primary Care guideline for the diagnosis and management of CMPA.13 CONFIRMATORY ALLERGY TESTS

The diagnosis of IgE-mediated food allergy is based on a combination of the clinical history and examination, allergy tests such as skin prick tests (SPTs) and/or serum IgE blood tests (sIgE), as well as oral food challenges where 40

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indicated.1,5 It is important to remember that SPTs and sIgE are tests that detect the presence of immunoglobulin E antibodies, but they cannot differentiate between sensitisation alone and clinical allergy.1 It is an unequivocal clinical history of a reaction after cow’s milk exposure, coupled with evidence of sensitisation that will help make a near certain diagnosis of CMPA in an infant.1 Oral food challenges can help resolve diagnostic uncertainty if there is an equivocal clinical history and negative tests, or if the allergy tests are positive but there is an unconvincing clinical history after exposure to cow’s milk.1 UNPROVEN TESTS

Determination of IgG antibodies or IgG subclass antibodies against cow’s milk protein has no role in diagnosing CMPA.5 In addition, hair analysis,

PAEDIATRIC applied kinesiology, provocation neutralisation, cytotoxicity assay and electrodermal testing, should not be used for diagnosing CMPA, as they have no validity and/or evidence to support their use.1 HOW IS CMPA MANAGED?

Management of CMPA involves the complete avoidance of all foods containing cow’s milk protein for a period of time – usually at least six months from diagnosis or until 12 months of age.

The proteins in cow’s milk are called whey and casein. Other mammalian milk proteins, such as goat or sheep milks should also be avoided, as proteins are up to 90% similar to cow’s milk proteins.2,5 BREASTFEEDING AND CMPA

Breastfeeding provides the best source of nutrition for babies and mums of infants with CMPA should be supported and encouraged to continue breastfeeding for as long as they would like to, preferably up to two years as recommended by the World Health Organisation (WHO), alongside the introduction of solid foods from around six months.10 Research has shown many benefits of breastfeeding, such as decreased prevalence of overweight/obesity in children who have been breastfed,11 decreased incidence of gastrointestinal and respiratory infections, improved neurological outcomes and favourable gastrointestinal microbiome.12 Occasionally, breastfed babies may react to the milk proteins in breast milk and, in this case, the mum will need to avoid all dairy products from her diet whilst breastfeeding.

This is usually done as a trial for between two and six weeks to see if an infant’s symptoms improve and then reintroduce to confirm if the symptoms return. If they do not return, then the mum should be advised to return to a normal diet.8,9 The decision as to whether a breastfeeding mum should also avoid soya products is very

individual and should be discussed with a dietitian or doctor.

Ideally, a dietitian should assess the calcium intake of the breastfeeding mum, as her calcium requirement is high at 1250mg/day. A calcium supplement should be suggested if her intake is inadequate, as well as a vitamin D supplement of 10 micrograms per day. Calcium phosphate supplements are better absorbed than calcium carbonate or lactate.1 A breastfeeding mum avoiding dairy products may also need an iodine supplement, as dairy products are one of the main sources of iodine in the UK diet, along with white fish.

APPROPRIATE FORMULAS

Extensively hydrolysed formula If an infant is on an infant formula with or without any breast milk, this will need to change to a hypoallergenic infant formula. These formulas are by prescription only. For a list of different brands available, please see Part 2 of this article in the next issue of NHD. PLEASE NOTE: Partially hydrolysed formulas available online or over the counter are not suitable for the treatment of CMPA. What about soya formula?

Soya formula is not recommended for babies under six months of age. For babies over six months, this may be a suitable option, but at least 50% of infants with non-IgE-mediated or delayed CMPA also react to soya protein and, therefore, soya formula (or soya milk used in foods) is not a suitable alternative in this group of children.

Extensively hydrolysed formulas are the first-line formula choice for infants with CMPA who are not breastfed.1,2,5 Conversely, in infants with IgE-mediated or immediate onset CMPA, most will tolerate soya. It has been reported that approximately 10-15% of children with IgE-mediated CMPA do not tolerate soya.1,2,5 Calcium fortified soya products can be a useful addition to the weaning diet of an infant with CMPA.

Part 2 of Paula’s CMPA and weaning article will focus on the reintroduction of allergenic and dairy-free foods and micronutrient management. Look out for this in the November issue of NHD.

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PKU sphere™ Vitaflo’s first GMP-based protein substitute specifically designed to optimise adherence.

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PKU sphere™ is a food for special medical purposes and must be used under medical supervision.

For the dietary management of PKU. *PKU sphere chocolate contains 2.8g / 20g PE and 2.2g / 15g PE. Contains: milk, soya, fish.

NEW STUDY INTO WEANING AND PKU

RESEARCH

Does the introduction of a second-stage weaning protein substitute affect growth in infants with PKU? A recent study

by Sharon Evans, Anne Daly and Anita MacDonald et al1, looks into growth, energy and protein intake.

In infants with PKU, introducing a second-stage semi-solid weaning protein substitute (WPS) is common, but there is concern that this may not meet energy requirements. A case-control study1 conducted earlier this year, has looked at growth in children with PKU who take a weaning protein substitute up to the age of two years. Protein and energy intake were also studied.

Weaning in PKU is particularly complex and challenging, as solid foods can suppress the appetite for liquids, potentially lowering intake of infant protein substitute, thereby affecting the ability to achieve total protein requirements. As a consequence, it often becomes necessary to introduce a second stage, more concentrated protein substitute2 at around six months of age. Feeding problems are known to be more common in young children with PKU compared with those without PKU3 and so the weaning period may be a particularly vulnerable time for achieving optimal growth.

Previous limited retrospective data has demonstrated that a weaning protein substitute can be introduced without adverse effects on appetite or growth.4 However, no studies until now have prospectively looked at growth, protein and energy intake of children during the weaning period and early years. There is concern that the low energy density of weaning protein substitute (8kcal/g protein) might not compensate for the energy content of infant protein substitute (33.5kcal/g protein) and this may impact on growth and weight gain.

This longitudinal, prospective study1 looked at 20 children with PKU who were transitioning to a WPS, and 20 non-PKU controls, Subjects were recruited to assess their growth, energy and macronutrient (protein, fat and carbohydrate) intake from the introduction of a second stage, low volume, Phe-free protein substitute (three to six months of age) to the age of two years (total of 17 to 20 months follow-up), observing them monthly from weaning commencement (four to six months) to 12 months and at 15, 18 and 24 months of age for: weight, length, head circumference, BMI, energy and macronutrient intake.

The weaning protein substitute (PKU Anamix First Spoon) was a powdered Phefree protein substitute supplemented with long-chain polyunsaturated fatty acids (LCPs), containing essential and non-essential amino acids, carbohydrate, fat, vitamins, minerals and trace elements. The product was mixed with water to produce a semi-solid spoonable protein substitute and 5g of protein substitute powder provided 2g of protein and 16 kcal.

RESULTS

Growth parameters were within normal range at all ages in both groups, with no significant difference in mean z-scores, except for accelerated length in the PKU group. No child with PKU had z-scores < â&#x2C6;&#x2019;2 for any growth parameter at age two years. Total protein and energy intake in both groups were similar at all ages; however, from 12 to 24 months in the PKU group, the percentage of energy intake from carbohydrate increased (60%), but from fat decreased (25%) and inversely for controls (48% and 36%). In PKU, use of low volume WPS meets Phe-free protein requirements, facilitates transition to solid foods and supports normal growth.

CONCLUSION

Normal growth was observed in the group of children with PKU, who were weaned onto a second-stage semi-solid protein substitute, compared with their non-PKU peers. The study concluded that further studies into longitudinal growth, body composition, energy/nutrient intakes in early childhood and adolescence would be beneficial in establishing any changing trends that may affect long-term health outcomes.

For references please visit the Subscriber zone at NHDmag.com/references.

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IMD WATCH

KUVAN OR SAPROPTERIN: A PHARMACOLOGICAL TREATMENT FOR PKU What is it and how could it help patients currently taking a highly complex low phenylalanine (Phe) diet?

Suzanne Ford, Dietary Advisor to NSPKU Suzanne is a Metabolic Dietitian working with Adults at North Bristol NHS Trust and also for the National Society of Phenylketonuria (NSPKU).

REFERENCES Please visit the Subscriber zone at NHDmag.com

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The rare genetic metabolic disorder Phenylketonuria (PKU), affects around 1 in 10,000 people in the UK.1 It is estimated that there are around 6000 people in the UK living with PKU, with only half of these under active metabolic follow-up. PKU is a lifelong disease and it is now established that treatment is, therefore, needed lifelong,2,3 the only treatment option in the UK being a low Phe diet, administered by a caregiver during infancy and childhood and, subsequently, by the individual patient as they transition into adulthood.

Treatment is aimed at reducing Phe levels towards a safe range, using a diet that is devoid of almost all natural sources of protein (ie, meat, fish, eggs, soya, nuts cheese, bread, pasta and milk). Instead, a synthetic protein substitute, with added vitamins and minerals, is taken throughout the day.

Regular dietary review by a specialist metabolic team is necessary to avoid nutritional deficiencies and encourage dietary adherence.

A survey of patients in the UK by the National Society for Phenylketonuria (NSPKU), shows that many struggle with this treatment as it is not delivered effectively in primary care and puts an undue burden, such as emotional stress, on caregivers or the individual patient.4 Walter and White (2002)5 illustrated that metabolic control is lost in early teenage years with current treatment. The timeconsuming and socially excluding nature of the diet is difficult to manage; evidence suggests that the time needed to administer diet by caregivers of children with PKU was 19 hours per week.6

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Similarly, the metabolic control of selfcaring adults managing the PKU diet whilst in employment, was reported

by Riva et al (2017)7 and showed that full-time employment worsens control compared to part-time employment.

Neurocognitive outcomes are a concern for those with PKU, as research shows Phe levels impact on executive function, such as working memory, problem solving and flexible thinking.8 Even for patients who are effectively managing their own dietary treatment and have been treated following a positive newborn screen (early treated PKU: ETPKU), there are suboptimal outcomes reported in individuals with PKU in terms of being 5-7 IQ points lower when matched with non PKU siblings.9 To summarise, dietary treatment is restrictive, complex, burdensome and suboptimal with regards outcomes.

WHAT IS KUVAN/SAPROPTERIN, OR BH4 (TETRAHYDROBIOPTERIN)?

BH4 (Kuvan) is currently the only drug treatment licensed for PKU in Europe.

Kuvan, or sapropterin, is a synthetic form of BH4, a substance that naturally occurs within the body. BH4 stimulates the enzyme phenylalanine hydroxylase (PAH – Figure 1 overleaf), which does not function correctly in people with PKU, and restores its ability to metabolise Phe. The deficiency in people who have PKU is associated with their enzyme activity and the enzyme’s functioning is closely related to its shape (shape determines configuration and efficacy of an enzyme’s active site).

IMD WATCH BH4 (Kuvan) is a helper or chaperone molecule for PAH; it makes the enzyme into a more functional shape, thus improving PAH activity and improving Phe tolerance;10 that means a person with PKU who responds to Kuvan can eat more protein, ie, it means dietary liberalisation.

In the context of PKU, BH4 keeps blood Phe levels low and stable, (lower and stable Phe is associated with better outcomes).11 People with PKU taking Kuvan can eat more natural protein (typically two or three times more), which improves their nutrition and changes the patient’s diet from abnormal to a more normal diet, and compliance with diet improves as evidenced below.

THE EVIDENCE BASE AROUND KUVAN

There is a body of evidence about the efficacy of BH4 in reducing blood Phe levels and allowing patients to take more natural protein, take less protein substitute, use lower volumes of lowprotein foods and, in some cases, come off diet entirely.12-14 There is also long-term-use data supporting the safety aspects of BH4 use.15 From a patient perspective, the effects of a liberalised diet does impact on quality of life. Even relaxing diet by having more exchanges in a day is liberalising, as patients can access vegetarian foods that are usually unsuitable for people with PKU. The effects of dietary liberalisation upon quality of life are not well evidenced in the literature, only the more objective quantitative measures, such as Phe. There is only a small amount of evidence so far. Nevertheless, BH4 is seen to reduce the impact of poor outcomes in PKU patients. Huijbregts et al (2018),16 specifically demonstrates poor outcomes in adult patients with PKU, showing that those >16 years old have worse experiences of cognition, sleep, pain, sexuality and anger than controls, and some of these relate to metabolic control (dietary treatment may have intrinsic effects on quality of life).

However, happiness, anger and social functioning scores improve with use of BH4/sapropterin independent of metabolic control, illustrating the social exclusion and negative effects of dietary treatment. This work supports other quality of life studies in the population of PKU patients taking diet and compared to those taking Kuvan.17,18 IS KUVAN SAFE AND DOES IT HAVE SIDE EFFECTS?

Long-term safety data has been collected on

Figure 1: Tetrameric structure of the enzyme PAH

sapropterin for long-term use – in reality it has been in use by patients for well over 10 years now. The summary of product characteristics19 for sapropterin reports headache and rhinorrhea as very common adverse reactions, occurring in ≥1/10 of people treated with sapropterin.

Common adverse reactions (occurring in ≥1/100 to <1/10 people treated with sapropterin) include hypophenylalaninaemia, pharyngolaryngeal pain, nasal congestion, cough, diarrhea, vomiting, abdominal pain, dyspepsia and nausea.

BACKGROUND, CONTROVERSY AND RECENT NEWS ABOUT KUVAN

Patients in the UK who are having Kuvan are very small in number at the time of writing, and most are prescribed on compassionate grounds. The Declaration of Helsinki, developed for the medical community by the World Medical Association, is widely regarded as the cornerstone document on human research ethics.20 Thus, there is a small number of children and adults taking Kuvan in the UK who have assisted in research and in return, in the absence of commissioning of the drug, receive long-term compassionate use of the drug.

Earlier this year the PKU Association Ireland (PKUAI) announced they had been made aware that KUVAN® (sapropterin dihydrochloride) had been approved by the Irish Health and Safety Executive Senior Leadership team and would be available in specific circumstances to our patient group for reimbursement from 1st July 2019.21 NSPKU, KUVAN, PATIENT POWER

The required standard for the volume, quality and power of an evidence base to support commissioning is very high, but difficult to meet in a small patient population, as the www.NHDmag.com October 2019 - Issue 148

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IMD WATCH Figure 2: PKU diagram of inheritance

A patient can undergo responsiveness testing by maximising their Phe tolerance before starting any BH4/Kuvan and then starting a calculated dose of BH4, undertaking twice weekly bloodspots whilst keeping Phe intake at baseline.23 If the patient responds, the bloodspot results will fall and subsequently the diet can be liberalised once response has been demonstrated.

USE OF KUVAN IN THE UK

England A possible interim policy by NHS England (England only) could lead to commissioning, as, in December 2018, NHS England published a draft interim policy for Kuvan, but did not fund the treatment for cost reasons. It was accepted that there was sufficient evidence to support the use of Kuvan, but it was then not prioritised for funding in July. NHS England has said this will be reconsidered in November 2019. comparatively lower resources and patient numbers limit the ability to conduct high powered randomised controlled trials. NSPKU has campaigned to all parties involved with the commissioning of Kuvan in the UK, including NICE, who evaluate evidence during the treatment commissioning process.

PRACTICAL USE: HOW IS KUVAN RESPONSIVENESS TESTED AND, IF A PATIENT IS RESPONSIVE, HOW IS THE DOSE DECIDED?

DNA analysis can be used to predict if a person with PKU will respond to Kuvan as described

by Trefz.22 In some countries, DNA testing is routinely done so that the patient’s PAH mutation is known soon after diagnosis. There are certain mutations associated with responsiveness and some with null responsiveness (a ‘null’ mutation). For each gene, there are two ‘alleles’ and one allele is inherited from each parent (see Figure 2). If a patient has two ‘null’ alleles in their PAH gene, then they will not be a responder.

We can only estimate the proportion of the UK population of people with PKU who would respond, thought to be about 30% of the patient group. This estimate is based on what is thought about certain PAH mutations being prevalent in the UK PKU community, compared with other European countries.

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Scotland In August 2018, the Scottish Medicines Consortium (SMC) stated that after careful consideration of all the evidence, the SMC Committee has been unable to recommend this medicine for use by NHS Scotland.

Wales and Northern Ireland There are no separate arrangements in place for commissioning Kuvan.

Kuvan is used in: Austria; Belgium; Bulgaria; Czech Republic; Denmark; Estonia; France; Germany; Hungary; Italy; Ireland; Latvia; Lithuania; Luxembourg; Netherlands; Norway; Portugal; Romania; Russia; Slovakia; Slovenia; Spain; Switzerland and Turkey.

CONCLUSION

Kuvan is a safe and effective treatment for PKU. Thousands of people with PKU use Kuvan (BH4) outside the UK, as it is provided by most European health systems. It has been available since 2008 in the EU but, as mentioned above, has never been commissioned by the NHS except for pregnant women with PKU. Kuvan is safe and clinically effective, as well as being cost effective compared with potential costs of maternal PKU syndrome, and is deemed safe in pregnancy.24

ACTIVATED CHARCOAL: ARE THE NUTRITIONAL CLAIMS JUSTIFIED?

DIET TRENDS

The craze for ‘activated charcoal’ (AC – also known as activated carbon) took off last year, with health claims making it sound like a miracle detox solution. Here, Alice Fletcher dispels the myths behind AC. The trend for AC appears to have died down a bit of late. Trendy cafes were selling shots of charcoal infused water and Gwyneth Paltrow continues to plug charcoal lemonade on her website describing it as the ‘best detoxifier’ around. You have probably seen charcoal facemasks that are famously very difficult to remove and actually end up waxing your face (trust me), as well as bloggers brushing their teeth with black charcoal powder before showing off a set of pearly white gnashers.

If you are super trendy, you may have even stumbled across charcoal infused croissants and burger buns (which yes, look very black – not particularly appetising!). You can even get (black) charcoal ice cream. Imagine spilling that down your tunic.

AC capsules can be purchased in health food shops and online, with descriptions including: 'It is important to help your body eliminate toxins to promote a healthy digestive system and brain. Chronic exposure to toxins produces cellular damage, allergic reactions, compromised immunity, and more rapid aging.' and, 'Regular use of activated charcoal is easy on the colon and can leave you feeling renewed and more vibrant.'

The claims regarding AC usually come with the pills and powders, not the Instagramable black ice cream cones and burger buns, where the black food is more for photographic effect. Powdered charcoal can be purchased in specialist culinary shops for this purpose.

AC is typically made from carboncontaining material, like wood, which is heated at high temperatures to create

charcoal, then oxidised (a process known as ‘activation’). AC is sometimes made by heating up coconut shells to very high heats. This process works to increase the surface area of molecules by giving it lots of pores, in effect, making it act like a sponge.1 Indeed, some ‘super activated’ charcoal preparations have a surface area of up to 175,000m2 per 50g bottle. This allows the ‘adsorption’ of drugs through weak intermolecular forces, with non‐ionized, organic compounds binding more avidly than dissociated inorganic ones.2

Alice Fletcher RD Countess of Chester NHS Foundation Trust (Community Dietitian) Alice has been a Registered Dietitian for five years, working within NHS community-based teams. She is passionate about evidence-based nutrition, cooking and dispelling diet myths.

DOES AC DETOX THE BODY?

Scaremongering regarding hidden toxins within the food we eat and the air we breathe may push people to purchase AC, or a similar product that promises to help our body to detox itself more effectively.

AC is adsorbent (has a high capacity to bind), easily confused with absorbent.

For this reason, AC supplements available in health food shops recommend leaving at least two hours between other medications when taking the supplement.

Such over-the-counter supplements are commonly recommended to be taken as two to four capsules up to three times per day with food.3 Ironically, AC’s high adsorbency also means that the ‘superfood’ fruit smoothie with added AC may have less of its vitamins and minerals left for your gut to absorb, as they have been mopped up and are no longer bioavailable.

Unfortunately, the ‘toxins’ that over-thecounter AC capsules claim to rid us of are not named – a common theme with ‘detox’ products on the whole.

REFERENCES Please visit the Subscriber zone at NHDmag.com

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DIET TRENDS DOES AC REDUCE THE ABSORPTION OF TOXIC SUBSTANCES/DRUGS FOR POISONING?

AC is listed within the BNF under indication ‘Reduction of absorption of poisons in the gastrointestinal system’ only.4 Clinically, it is available as an oral suspension (AC 200mg per 1ml), or in granule form (with AC 813mg per gram). It is only effective for certain medications, such as quinidine sulphate and aspirin.

The suggested dose for treating a case of poisoning is 50g of product for an adult. This equates to over 40,000mg of AC. In contrast, capsules purchased in a leading health food shop as a supplement (for wind and bloating) contain only 334mg each; three pre- and three post-meal are recommended, with a maximum of 12 per day.5 However, 12 capsules would equate to 4000mg, 10% of the dose needed to treat acute poisoning.

The American Society of Toxicology produced a position statement in 1997 stating that: ‘administration of AC may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to one hour previously; there is insufficient data to support or exclude its use after one hour of ingestion. There is no evidence that the administration of AC improves clinical outcome.

Unless a patient has an intact or protected airway, the administration of AC is contraindicated.’6 DOES IT REDUCE HANGOVERS?

AC has been claimed online to help reduce hangovers by binding with alcohol. You may have seen recipes for black charcoal cocktails, which promise to leave you feeling fresher than you otherwise would have. You have probably already guessed that this is not the case, as, unfortunately, AC does not bind well with alcohol.

Clinically, AC is rarely used in pure alcohol poisoning, since alcohol is absorbed rapidly from the gut. In early reports, AC was found to adsorb alcohol poorly.7 However, in 1981, scientists demonstrated in dogs that AC given at the same time as alcohol can reduce the blood alcohol concentration significantly.8 To study whether AC is of value in a clinical situation, a randomised cross-over study in two phases was conducted. Each person drank 88g of alcohol and 30 minutes afterwards, either 20g of AC was taken, or the same volume of water was 48

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drunk. Significant differences in plasma alcohol concentrations with or without AC were not found.9 HOW ABOUT REDUCING WIND AND BLOATING?

An in vitro and in vivo study in 1985 found that AC does not influence gas formation in vitro or in vivo,10 but interest in this possible gas trapping function of AC continued.

In 2011, the European Food Safety Authority (EFSA) produced an opinion paper regarding the gastrointestinal claims around AC. They concluded that AC can be sold with the conditions of use that it can be labelled as, ‘traditionally used to contribute to good digestive comfort’, or ‘usually known for its contribution to good digestion’ in the dosage powder equivalent to 400mg of drug daily.11 On the basis of the data presented to them, the EFSA Panel concluded that a cause and effect relationship had been established between consumption of AC and reduction of excessive intestinal gas accumulation. The panel considered that in order to obtain the claimed effect, the intake of AC should be 1g at least 30 minutes before consumption of a meal and 1g after the meal.

In one of the studies discussed within this opinion paper, researchers conducted a doubleblind clinical trial on two population groups in the United States (n = 30) and India (n = 69) known to differ in their dietary habits and ecology of gut flora.

Using lactulose as the substrate, breath hydrogen levels were measured to quantify the amount of gas produced in the colon. In comparison to a placebo, AC significantly (p less than 0.05) reduced breath hydrogen levels in both the population groups. Self-reported symptoms of bloating and abdominal cramps attributable to gaseousness were also significantly reduced in both groups

by AC.12 Another study measured the amounts of flatus (self-reported – nobody wants that job!) over a defined period, finding orally administered AC to significantly reduce these events.13 However, following on from these studies in the eighties, a longer (albeit small) study in 1999 used five healthy human volunteers who ingested 0.52g of AC four times daily for one week. The faecal liberation of intestinal gases was measured before and after the AC treatment.

Ingestion of AC neither produced significant reduction in the faecal release of any of the

sulphur-containing gases, nor was total faecal gas release or abdominal symptoms significantly influenced.14 This is, however, a relatively small dose compared with other studies, which may well have impacted upon the findings.

On the basis of the data presented, the EFSA Panel concluded that a cause and effect relationship had not been established between consumption of AC and reduction of bloating.11 I could not find any studies comparing the likes of a low-FODMAP diet to a diet supplemented with charcoal capsules, and charcoal does not feature in NICE guidance for diagnosed IBS. DOES AC REDUCE DIARRHOEA?

Cancer Research UK state that 10-20% of people receiving the chemotherapy drug irinotecan (Campto) report severe diarrhoea.15 A prospective study to evaluate the efficacy of AC to prevent irinotecan-induced diarrhoea, found that the use of AC decreased the frequency and severity of diarrhoea, which also improved compliance with treatment. Within this study (in children) the experimental group received AC at a dose of 250mg three times daily during irinotecan administration.

A total of 28 events of diarrhoea were registered, 13 in 45 cycles (28.88%) in the experimental group and 15 in 21 cycles (71.42%) in the control group.16 Diarrhoea can present itself alongside a multitude of treatments and conditions aside from chemotherapy, including intestinal, colorectal and pancreatic cancer, bacterial infection and IBS, making AC a potential therapy in these conditions. Overall, further research is necessary in order to determine the effectiveness of AC in the management of diarrhoea.

AC in large doses can cause constipation, a laxative is advised alongside its use for overdose/accidental poisoning because of this and it is often clinically formulated to include sorbitol for this reason. There have been case reports of bowel obstruction from AC, but this was following large doses of AC following drug overdose, not every day supplementation.17,18 DOES AC REDUCE THE DECLINE IN KIDNEY FUNCTION IN PEOPLE WITH END STAGE CKD?

The effects of oral adsorbents such as AC have been looked into as a method of delaying

progression or preventing chronic kidney disease (CKD), which is a huge global public health problem. Deterioration of kidney function causes an increase of uraemic toxins in the blood, which in turn promotes CKD progression. Oral adsorbents, including AC, have the ability to adsorb and remove uraemic toxins secreted and produced in the gastrointestinal tract and eliminated in faeces.

These have been used in clinical practice to decrease kidney injury.

A Cochrane review included 15 studies which recruited 1590 participants, using RCTs only. It was found that oral AC granules may have beneficial effects on retarding the decline of kidney function, with no serious adverse events for patients with CKD. Unfortunately, the studies included were generally of poor methodological quality.

Currently, there is no strong evidence for recommending any oral adsorbents, such as AC, for preventing or delaying the progression for patients with CKD.20 More research is needed, but this is certainly an interesting direction of study.

SUMMARY

It seems that the power of detox will continue to be plugged until the end of time. In April this year, The Lancet published results from 27 years of data collected from across 195 countries, finding 11 million deaths and 255 million disability-adjusted-life years were attributable to dietary risk factors. High intake of sodium, low intake of wholegrains and fruits were the leading dietary risk factors for deaths and disability-adjusted-life years globally. The need to prioritise and promote sensible dietary patterns above pricey detox products continues. www.NHDmag.com October 2019 - Issue 148

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F2F

FACE TO FACE Ursula meets: DR LAURA THOMAS Registered Nutritionist Author of Just Eat It

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

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Director; London Centre for Intuitive Eating

In 1792, Mary Wollstonecraft wrote A Vindication of the Rights of Woman. She observed that women were, ‘taught from their infancy that beauty is a woman’s sceptre, the mind shapes itself to the body and, roaming around its gilt cage, seeks only to adore its prison.’ Young Mary was furious that for many young women (in 1792), their self-worth and confidence was entirely linked to their beauty and shapeliness. Laura looked alarmed. Was I really going to continue reading ancient texts on body image to her? She wanted to talk about current concepts of behavioural techniques to support those with disordered eating, and I was ready to learn.

Laura grew up in Aberdeen and went to university there. Her first degree was in Human Health with Nutrition. Her final year project was at the Rowett Institute, examining the effects of probiotics on bifidobacterial species. “It was a small project, but introduced me to the excitement of research,” she said.

Thanks to distant family connections, she flew off to do her PhD at Texas A&M University. Even though she had been on family visits, it was a bit of a culture shock. “I had to work really hard doing teaching and laboratory work in parallel with my project on the microbiome. And then, disaster, the supervisor left and I had to start afresh on a new research topic.” After four years she completed a dissertation on tracking behaviour change using the latest online dietary assessment

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Ursula meets amazing people who influence nutrition policies and practices in the UK. tool, ASA24®. She was inspired when a supervisor explained that PhD-ing afforded you the skills to be able to find answers to questions, even if the problem wasn’t in your immediate area of expertise.

She really enjoyed an internship in Washington DC with the consumer advocacy group Centre for Science in the Public Interest (CSPI). “I got to see how developing political contacts and lobbying function. They worked so hard to support better health and information for consumers,” said Laura.

In 2012, she got a post-doc job at Cornell University in Ithaca New York, supporting nutrition education in schools and in lower income communities. Laura did a lot of travelling around New York state to deliver seminars, evaluate projects, and to research educational formats to support better diets. “We discovered what is perhaps obvious in hindsight.

Poor food choice in low income groups is not just about having less money to spend on foods, or a lack of knowledge.

Rather it is about complex socioeconomic constraints,” Laura said.

On a clear blue day, Laura decided that what she really wanted, was to return to the UK and work for herself. She moved to Leeds to set up as a freelance nutritionist. She noticed the prolific digital presence of ‘wellness’ advisors and became increasingly concerned and annoyed at the nutritional untruths being declared by those least qualified.

It was time for cyberbattle.

F2F

Laura goes on to tell me about intuitive eating . . .

“It is about learning, or relearning, moving for pleasure and choosing foods that support health, but without rules and rigour.”

Laura developed a blog and produced regular podcasts: Don’t Salt my Game, to comment on nutrition claims and counterclaims. Romance pulled her to a fresh start in London and she decided to focus her work on behavioural and non-diet approaches to disordered eating.

“There are lots of great online courses on this,” said Laura. She also mentions that she has just completed her PGDip in Eating Disorders and Clinical Nutrition at University College London.

Laura goes on to tell me about intuitive eating. This means breaking down the many eating rules that fill the headspace of those with disordered eating, and helping them to learn to recognise and trust internal body cues again. There are many reasons for disordered eating, and there are different paths supporting improved food choices. “It is about learning, or relearning, moving for pleasure and choosing foods that support health, but without rules and rigour.” And particularly not banning ‘unhealthy’ foods, which always leads to the oftdescribed siren pull of ‘forbidden fruit’.

Laura has now set up a support centre for disordered eating (www.londoncentre forintuitiveeating.co.uk), where she works with two dietitians and an administrator. The website offers online courses on intuitive eating for parents concerned about their children’s food habits. She will also be hosting a two-day workshop for health professionals in London

and in Edinburgh in October (see website).

For dietitians looking to develop their skills in this area, Laura strongly advises appropriate courses and training, multidisciplinary support, professional supervision and reflective practice.

As well as setting up the support centre, the last year has been very busy for Laura. “I approached a literary agent about possible nutrition book projects. He identified strong interest on the subject of intuitive eating and Bluebird Books signed up to the project. The result is the pink sugar doughnut delight entitled Just Eat It. How intuitive eating can help you get your . . . “It was more work than doing a PhD, but has been a very rewarding experience,” said a beaming Laura.

Laura’s office is calm and cosy and her thoughtful manner and scented candle aroma lull me into confession mode. My food choices are sometimes bizarre and constitute about one third of what I eat. Laura looked alarmed. I told her about my opposite of disordered eating. Rather, ‘ordering’ eating. Which means the regular cull of fridge or cupboard items, scraps, or end of shelflife items bought on impulse by teenagers, which a waste-reduction mother can’t bear to throw out. It’s ‘tidy-up’ eating. I asked Laura whether she thought this was weird. “Perhaps, but it’s not disordered,” was her answer.

Clearly, the advice was to talk to the disordered teens. (I was most impressed with Laura’s therapeutic skills!) www.NHDmag.com October 2019 - Issue 148

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A DAY IN THE LIFE OF . . .

A FOOD AND HEALTH DEVELOPMENT WORKER Lesley Curtis tells us about her role in Edinburgh, forging ahead on the path to a sustainable food city.

Lesley Curtis Registered Associate Nutritionist, Edinburgh Community Food Food and health development work has been Lesley’s first role since becoming a Registered Associate Nutritionist.

Working with communities, reducing health inequalities and promoting a healthy, sustainable lifestyle is what she is most passionate about.

My nutrition career began in September 2018, when I relocated from Somerset to the other end of the country and joined Edinburgh Community Food. The organisation is a citywide charity and social enterprise that aims ‘to get people into healthy food and healthy food into people’.

The organisation’s development work aims to reduce health inequalities in the most vulnerable communities and as a Food and Health Development Worker, I have run several cooking courses with a variety of vulnerable communities across Edinburgh, including with women in the criminal justice system, older adults, new parents and low-income families. In March this year, I also took on the role of the Sustainable Food Cities Coordinator for Edible Edinburgh, the food partnership in the city.

Each working day is different and my work schedule varies from week to week, depending on the needs of the partnership. On a typical day, I have a run at 6am. I feel very lucky to live in such a beautiful city, one I can explore so easily. I’m training for a half marathon (off road) in November and a sprint triathlon taking place on New Year’s Day. After a shower and breakfast, I travel to the office via bus and arrive at 8am.

FOOD AND HEALTH DEVELOPMENT

Depending on the day, I will either plan and deliver cooking sessions, or organise and attend partnership meetings. I currently run two cooking groups per week and am in the planning stages for a third. I have recently set up a new cooking group with older adults at a 52

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sheltered housing complex. Each week we engage in a nutritional activity, aimed at older adults and then cook a healthy, nutritious meal at which we sit down together to eat. Every fourth week, following their tenants’ meeting, a volunteer and I will cook a meal for the residents for them to enjoy together.

The aims of this ongoing project are to reduce social isolation and increase the awareness of malnutrition.

My other cooking group is with families at a primary school in an area of deprivation. This cooking group aims to increase parental engagement with the school and reduce the children’s behavioural issues, using food and cooking as a vehicle to achieve this. These sessions are always lively and good fun, and parents are able to take home any leftover food we have made. Each cooking course at the school is six weeks and we are on the third course in this particular school. We recently promoted the national Veg Power campaign as an organisation, through our cooking groups.

I am also involved in Discover!, a free holiday programme run by City of Edinburgh Council’s Lifelong Learning Team. Discover! aims to help reduce food stress during the school holidays and to provide fun learning activities for children and experiences for families to share. My colleagues and I facilitate cooking groups for the Discover! programme at different locations across the city during each holiday period. We ran sessions over Easter and throughout the summer holidays and will be during the October half-term too.

A DAY IN THE LIFE OF . . .

together, we can make positive choices about food that are healthier and tastier and which bring social, economic and environmental benefits

Lesley and members of the Edible Edinburgh food partnership with their Bronze Sustainable Food Cities award.

EDIBLE EDINBURGH FOOD PARTNERSHIP

When I don’t have a cooking group, I’ll be working on the Edible Edinburgh partnership, a citywide, cross-sector partnership that aims to inspire and motivate everyone across Edinburgh to work together to build new approaches to food. The partnership believes that, together, we can make positive choices about food that are healthier and tastier and which bring social, economic and environmental benefits to the whole community.

There are five sub groups that focus on the specific food issues of Health and Wellbeing, Food Economy, Land Use, Food Waste and Cultural Change. Each sub group has key priorities to work towards, based on the Edible Edinburgh Sustainable Food City Plan. I am chair of the Cultural Change sub group, which has a current focus on planning partnership events and updating the Edible Edinburgh website and social media pages. I work closely with the Senior Policy and Insight Officer at the City of Edinburgh Council, and we try to meet every week or so to discuss the work of the partnership. We are currently planning a Business Breakfast event to engage businesses in the sustainable food agenda.

The partnership held a successful Edible Edinburgh Food Summit event in April this year and in preparation for this, my role

included finding a suitable venue, agreeing an agenda with the Secretariat, setting up and managing an Eventbrite page for attendees, confirming speakers, facilitating workstations and presenting on the day. This event provided a unique opportunity for stakeholders to hear about and engage with ongoing work across the public, private and third sector in and around the city, in order to build a healthier, fairer and more sustainable food system.

In addition, the partnership applied for the Sustainable Food Cities Bronze Award this year and I was responsible for compiling and submitting the award application. The good news is, we won the Bronze Award, which is fantastic evidence to show residents, policy makers, funders, businesses and tourists that Edinburgh is a nationally recognised city of good quality, sustainable, fair and local food that we can all be proud of.

My working day usually finishes around 4pm. I am extremely fortunate to have free time in the afternoons and I make the most of this by exploring the city, visiting the Pentland Hills, cycling, reading and seeing friends. Overall, no two days are the same in my job and I’m looking forward to seeing how the work of Edible Edinburgh develops and grows, as this is an exciting time to be involved with the food partnership. www.NHDmag.com October 2019 - Issue 148

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EVENTS & PUBLIC HEALTH COURSES THE ROYAL MARSDEN FOUNDATION TRUST 8th Nov 2019: The 11th Annual Royal Marsden Head & Neck Conference: ‘Head & Neck Cancer Management in the Elderly’ 12th Mar 2020: Foundation in Oncology for Speech and Language Therapists 14th Mar 2020: Everything you ever wanted to know about: The Role of Radiology in Cancer Diagnosis and Treatment For more information visit: www.royalmarsden.nhs.uk/news-and-events/ conference-centre/study-days-and-conferences

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

NUTRICIA PAEDIATRIC EXPERT MEETING, LONDON 6th-7th Nov 2019 A unique two-day free educational event covering a spectrum of hot topics in paediatric clinical practice. This event is intended for Healthcare Professionals only.

For full details visit: events.nutricia/uk

FOOD MATTERS LIVE - ExCeL LONDON Thought-provoking debate. Cross-sector collaboration. A carefully curated exhibition.

19th-20th Nov 2019 Food Matters Live is a unique event dedicated to creating cross-sector connections focused on the future of food, drink and sustainable nutrition. Thousands of visitors from across the global food and drink industry will come together, with hundreds of innovators in a carefully curated exhibition, while hundreds of speakers feature in an unrivalled educational programme. For more information visit: www.foodmatterslive.com/2019 EFAD CONFERENCE 2019 1st and 2nd November 2019 Berlin, Germany www.efadconference.com

THE FREEFROM SHOW WINTER 2nd and 3rd November 2019 Exhibition Centre Liverpool www.allergyshow.co.uk/liverpool

WORLD DIABETES DAY 14th November 2019 www.worlddiabetesday.org

BARIATRIC DIETITIAN - TRANSFORM AND THE HOSPITAL GROUP NEWCASTLE

£24,000 to £28,000 per annum, pro-rata (dependent on experience) 15 hours a week.

Here at Transform and The Hospital Group, we help people to enhance their wellbeing and quality of life. With two purpose-built hospitals and 20 clinics, we are one of the largest trusted providers in the UK, with our geographical footprint providing nationwide accessibility to our services. The Hospital Group is the UK’s leading private provider of bariatric (obesity) surgery, providing gastric balloon, gastric band, sleeve gastrectomy and gastric bypass surgery. We have an excellent opportunity for a Registered Dietitian to join our professional and enthusiastic team of clinical and non-clinical staff at our Newcastle clinic (with possible travel to other clinics nationwide). The role will mainly involve conducting telephone and face-to-face consultations with pre- and post-op bariatric patients. Depending on available resources, there may also be opportunity to update existing and create new patient literature; train in performing gastric band adjustments; be involved in clinical audit; be involved in training other colleagues in the Obesity Service. Please note: Strong IT skills are required as all patient notes are computerised. Touch-typing particularly desirable. Experience in bariatrics is desirable but not essential as full training will be provided. Your salary will reflect your level of experience in bariatrics.

Please send your most up-to-date CV to careers@transform.com

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EATING OUT WITH RESTRICTIONS Recently we organised a meal out for our patients who have Phenylketonuria (PKU) and who have to follow a very low-protein diet. Eating out for them is stressful, as most foods contain too much protein. Working out what to eat from a menu can be confusing and, if they were being strict, they would have to take along their kitchen scales and weigh out the foods which contain protein!

So, to take that stress away, a set menu was prepared for them that was very low protein. We chose a vegan plant-based restaurant, where many of the meals could be tweaked. The menu included tropical jackfruit stew, penne palmero (using lowprotein pasta) and pear crumble (using low-protein flour), custard (using rice milk) and sorbet. The food was great and we ate and chatted freely.

Recently, my niece was diagnosed with cowâ&#x20AC;&#x2122;s milk protein allergy (CMPA). This made me think about food labelling and how to work out which foods contain allergens, especially when eating out at a restaurant. Before the food allergen labelling laws were introduced in 2005, it must have been a nightmare trying to figure out which foods contained allergens. Now the ingredients that contain allergens have to be highlighted on the label by law.

In my role as the dietitian to the Galactosaemia Support Group (GSG), I educate on how to spot milk in foods using the label (as people with galactosaemia have to avoid galactose/ lactose). Before the labelling laws were introduced, the GSG produced a booklet that contained a long list of all the lactose-containing ingredients that had to be avoided and ingredients that sounded like they contained lactose but didn't! Thank goodness for the revised labelling laws; we only need to look for the word â&#x20AC;&#x2DC;milkâ&#x20AC;&#x2122; now!

Unfortunately, however, there are a couple of loopholes. Current EU regulations state that foods directly from dairy are products in their own right, eg, yoghurt, cream, cheese and butter. Therefore, they do not have to by law be declared as milk on the label, so caution needs to be followed when interpreting the labels.

Prepackaged foods currently do not have to follow the labelling laws for allergens, but this is changing. Natasha's Law will be introduced in the summer of 2021. Natasha Ednan-Laperouse tragically died as a result of an allergic reaction to a baguette she had eaten, which did not display allergen information on the packaging. The new law will mean that all foods prepacked for direct sale (eg, a sandwich or salad made and sold in the same premises) will have to be labelled with full ingredients. As well as helping allergy sufferers, this will also help people with galactosaemia to identify which prepacked foods contain milk.

Restaurants have to provide allergen information in writing, making it easier for the consumer to identify allergens.

Eating out on a restrictive diet is hard, but with planning it is possible. It is now much easier than it has been in the past due to allergen laws. Whether it be checking the menu beforehand for allergens, or looking up the amount of protein, fat or carbohydrate in the meals, it can be done.

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

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COW’S MILK ALLERGY

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