Network Health Digest - November 2019

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

The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

November 2019: Issue 149

SPORTS NUTRITION

CROHN'S AND ENTERAL NUTRITION KETONGENIC DIET: CASE REPORT CLINICAL SUPERVISION MALNUTRITION LECTIN-FREE DIET CHYLE LEAKS MALABSORPTION COW'S MILK PROTEIN ALLERGY PT2

Nutrition in Mental Health Recovery Pages 39-42

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HELPING KIDS BE KIDS AGAIN References: 1. Data on file. Abbott Laboratories Ltd., 2019 (IMS data, June 2018 - May 2019). 2. Data on File. Abbott Laboratories Ltd., 2007 (PaediaSure Plus & PaediaSure Plus Fibre taste testing). 3. Data on File. Abbott Laboratories Ltd., 2013 (PaediaSure Fibre taste testing). 4. Data on File. Abbott Laboratories Ltd., 2013 (PaediaSure & PaediaSure Peptide vs. Peptamen Junior Powder). 5. Data on file.

Abbott Laboratories Ltd., 2017 (Sensory research and evaluation: PaediaSure Plus vs. PaediaSure Compact).

Date of preparation: August 2019 ANUKANI190244

UP FRONT Over recent months, there have been quite a few big birthdays amongst my family and friends, all of which have been superb excuses for dining out and enjoying each other’s company.

Ensuring that everyone is catered for during any celebratory get together isn’t always smooth sailing. Finding a venue large enough to fit everyone in, on the date and at a time that suits the whole clan, can be a headache. The other major concern is finding eateries that cover everyone’s dietary requirements. However, the dietary requirement situation seemed relatively straightforward for all my recent family gatherings, and dare I say it, even for the vegans amongst us. Times are certainly a-changing!

Over the course of 2019, vegan diets have gathered ever more pace, with some major ‘firsts’ taking place and many top high-street brands introducing more plant-based foods into the mainstream than ever before. To start the year, Veganuary, with its campaign to inspire people to try veganism throughout the month of January (and potentially beyond), saw record numbers of people signing up and extending it throughout the year. We also saw the launch of Greggs vegan sausage rolls, which came about after 20,000 people signed a petition by animal welfare organisation, Peta, in 2018, calling on Greggs to produce a vegan version of its flagship item.

Vegan food is a rapidly growing market and the appetite for it doesn’t seem to be slowing up. The global value of meat alternatives alone is estimated to reach over £22 billion by 2023 and in the UK, the total value of the meat-free industry is expected to grow from £559m in 2016 to £658m in 2021. The market for meat-free alternatives has exploded, with something to suit most palates.

Our intake of non-dairy milks has increased over recent years too, with around 25% of UK adults opting for non-dairy alternatives; oat milk being a particular favourite. We’ve also seen traditional carveries and steakhouses introduce VF options to their menus, which would have been unheard of a few years ago. This will be a boon for some vegans who revel in the ever-expanding choice of places to eat. For others, these kinds of restaurants will still be off limits due to ethical reasons and the fact that meat and dairy is prepared and cooked in such close proximity.

This month, Cancer Research UK launched its ‘Veg Pledge’ campaign, which calls on participants to go vegetarian or vegan for a month throughout November to raise money to beat cancer. You can find more information about this campaign at www.cancerresearchuk.org.

As we edge closer to the foodie festivities of Christmas, we’ll see supermarkets provide a few extra vegan-friendly options this year. So, there are more opportunities than ever to ‘eat vegan’. Will Veganuary soon be redundant? Will it have achieved its goal in bringing veganism to the masses?

Well, it probably has some work left to do. The most recent statistics show that only around 7% of the UK population are now vegan. Nevertheless, I think it’s safe to say that 2019 has quite possibly been the year of the vegan!

Tuck into this nutritious serving of NHD, guaranteed to cater for all dietitians and nutritionists, whatever your dietary requirements! Emma

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

www.NHDmag.com November 2019 - Issue 149

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11 COVER STORY Sports nutrition 6

News

8

Lectin-free diet

Latest industry and product updates

Evidence of risks involved

15 Crohn's disease

Enteral feeding in remission

39 Mental Health

The role of nutrition in recovery 43 Ketogenic diet Case report

18 CLINICAL SUPERVISION

46 F2F

Interview with Jamie Blackshaw

21 CMPA Part 2

48 A DAY IN THE LIFE OF A dietitian advisor

Weaning implications

28 Chyle leaks

Aetiology, diagnosis and treatment

31 MALABSORPTION

50 Events, courses

& dieteticJOBS

Essential dates for

35 Malnutrition

A new approach to training staff

your diary

51 Dietitian's life

Veganuary: A challenge too far?

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

Editor Emma Coates RD

Advertising Richard Mair Tel 01342 824073

Publishing Director Julieanne Murray

richard@networkhealthgroup.co.uk

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

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

www.NHDmag.com November 2019 - Issue 149

@NHDmagazine

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FOR HEALTHCARE PROFESSIONAL USE ONLY

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References: 1. Boehm G et al. Arch Dis Child Fetal Neonatal Ed 200;86:F178-81. 2. Knol J et al. Acta Paediatr 2005;94(449):31-3. 3. Mihatsch W et al. Acta Paediatr 2006;95(7):843-8. 4. Bar-Yoseph F et al. Prostaglandins Leukot. Essent. Fatty Acids 2013;89(4):139-43. 5. Carnielli et al.

Am J Clin Nutr 1995;61(5):1037-1042. 6. Carnielli et al. J Pediatr Gastroenterol Nutr 1996;23(5):553-560. 7. Kennedy et al. Am J Clin Nutr 1999;70(5):920-7. 8. Quinlan et al. Pediatr Gastroenterol Nutr 1995;20(1):81-90. 9. Agostoni C et al. J Pediatr Gastroenterol Nutr. 2010;50:1-9.

10. Aggett PJ et al. J Pediatr Gastroenterol Nutr. 2006;42(5):596-603.

18-171. November 2018

NEWS CLINICAL

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

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MORE ACTION NEEDED TO ADDRESS CHILDHOOD OBESITY An independent report by the outgoing Chief Medical Officer, Professor Dame Sally Davies, titled, Time to Solve Childhood Obesity was published on 10th October, stressing that an obesogenic environment is the primary cause of the current obesity crisis in children.

In order to tackle childhood obesity, the report states that changes must be made to ensure children have a healthier environment to support better nutrition and activity levels, aiming to achieve the Government’s ambition to halve childhood obesity by 2030. Key outcomes from the report include: • having access to healthy and affordable food; • protection from marketing of unhealthy foods; • opportunities to run, cycle and play safely.

The report includes a wide range of recommendations, including improving NHS support in managing obesity, by ensuring all healthcare professionals have the skills and knowledge to understand weight stigma and empowering them to initiate conversations about weight with children and families. Recommendations also include supporting healthy choices and a healthy start by addressing excess weight in pregnancy, encouraging breastfeeding and supporting healthy eating in infancy; tracking children’s weight more effectively to allow earlier intervention and ensuring early years national food standards are developed.

Dame Sally Davies would also like to see caps on permitted calorie content and changes to VAT on food sold outside the home and the limited marketing of less healthy food and drink products at public events. She states that government has a responsibility to support children’s right to live healthy, active lives; and to protect and improve children’s health.

Read the full report here: www.gov.uk/government/publications/time-to-solve-childhood-obesity-cmo-special-report

FOOD DESCRIPTIONS HAVE AN EFFECT ON HEALTHY CHOICES A study from students at Stanford University in California, published in the journal Psychological Science in October,1 shows that giving vegetable dishes enticing descriptions can significantly increase the uptake of healthy options. Over a period of 185 days, the team analysed 137,842 decisions about 24 types of vegetables in 71 dishes with healthful, neutral, or taste-focused names. The researchers found that giving vegetables a taste-focused label increased the uptake of the meal by almost a third (29%) compared with using a health-focused label and by 14% compared with basic labels. Vegetable consumption also increased.

Alia Crum, Assistant Professor of Psychology and senior author on the paper, says that taste-focused food labelling works because "it increases the expectation of a positive taste experience. In particular, words that highlight experience, such as 'sizzling' or 'tavern-style,' help convey that the dish is not only tasty, but also indulgent, comforting, or nostalgic." Describing foods using nonspecific positive words, such as "absolutely amazing," did not increase uptake because they were too vague.

According to the researchers, the fact that college students in the US are the age group with the lowest intake rate of vegetables means that people should not underestimate these increases in healthful eating.

1 Bradley P. Turnwald, Jaclyn D. Bertoldo, Margaret A. Perry, Alia J Crum et al (2019). Increasing Vegetable Intake by Emphasising Tasty and Enjoyable Attributes: A Randomised Controlled Multisite Intervention for Taste-Focused Labelling. First Published October 2, 2019 Research Article. https://doi.org/10.1177/0956797619872191

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www.NHDmag.com November 2019 - Issue 149

NEWS DO WE REALLY NEED TO CUT DOWN ON RED AND PROCESSED MEAT? A new set of reviews1 published in The Annals of Internal Medicine, (published in October 2019), suggests that there is no need for adults to reduce their consumption of red or processed meat.

Authored by the Nutritional Recommendations (NutriRECS) consortium in the USA, systematic reviews were performed on cardiometabolic, cancer and all-cause mortality from cohort and randomised controlled trials. People’s health-related values and preferences in relation to red and processed meat were also reviewed.

Overall, the quality of evidence found by the reviews was considered to be low and the consortium suggests that adults could continue to consume current volumes of red and processed meats. This was due to outcomes being too small or insignificant to recommend otherwise.

However, health bodies, including Public Health England, Cancer Research UK and the World Cancer Research Fund, have challenged this conclusion.

Although the increased risks related to consuming red and processed meat consumption are relatively small, if considered across the wider population, its effects could be more of a concern.

An example of one finding from the reviews included that reducing consumption of red or processed meat by three servings per week could result in between 1-12 fewer cases of Type 2 diabetes per 1000 people. When applied to the wider population of millions of people, this could potentially result in hundreds of thousands of fewer cases.

The World Cancer Research Fund recommends that there is no need to completely avoid eating meat, but advises that no more than 500g of red meat per week fits into a healthy balanced diet. The Government guidance suggests that adults may benefit from a reduction in red meat consumption.

1 Johnston BC, Zeraatkar D, Han MA et al. Unprocessed Red Meat and Processed Meat Consumption: Dietary Guideline Recommendations; from the Nutritional Recommendations (NutriRECS) Consortium. Ann Intern Med. 2019; [Epub ahead of print 1 October 2019]. doi: 10.7326/M19-1621

SYSTEMATIC REVIEW ASSESSES EFFECTS OF POLYUNSATURATED FATS ON DIABETES An extensive systematic review from the Norwich Medical School examined trials to date including previously unpublished data to assess effects of polyunsaturated fats on newly diagnosed diabetes and glucose metabolism. The review suggests that increasing omega-3, omega-6, or total PUFA has little or no effect on prevention and treatment of Type 2 diabetes mellitus.

Randomised controlled trials of at least 24 weeks’ duration were included, which assessed the effects of increasing α-linolenic acid, long-chain omega-3, omega-6, or total PUFA and which collected data on diabetes diagnoses, fasting glucose or insulin, glycated haemoglobin (HbA1c), and/or homoeostatic model assessment for insulin resistance (HOMA-IR). A total of 83 RCTs (mainly assessing effects of supplementary long-chain omega-3) were included in the review.

Long-chain omega-3 had little or no effect on the likelihood of diagnosis of diabetes or measures of glucose metabolism. A suggestion of negative outcomes was observed when dose of supplemental long-chain omega-3 was above 4.4g/d. Effects of α-linolenic acid, omega-6 and total PUFA on diagnosis of diabetes were unclear (as the evidence was of very low quality), but little or no effect on measures of glucose metabolism was seen, except that increasing α-linolenic acid may increase fasting insulin (by about 7%). No evidence was found that the omega-3/omega-6 ratio is important for diabetes or glucose metabolism.

For details of the review visit: https://doi.org/10.1136/bmj.l4697. (BMJ 2019; 366: l4697. Published 21 August 2019.)

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DIET TRENDS

THE LECTIN-FREE DIET Lectins are a group of proteins that cause red blood cells to clump together by binding to carbohydrates.1 The lectin-free diet involves heavily restricting lectins such as gluten and certain lectin-containing foods. This article looks at the evidence for and risks involved in this restrictive diet.

Maeve Hanan UK Registered Dietitian Freelance

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

REFERENCES Please visit: https://www. nhdmag.com/ references.html

The lectin-free diet has been promoted by an American cardiologist called Dr Steven Gundry (author of The Plant Paradox), and has been further popularised by celebrities such as Gwyneth Paltrow and Kelly Clarkson. In fact, last year, Kelly Clarkson hit the headlines with the dramatic claim that due to the lectin-free diet, she no longer needs medication for an autoimmune condition and that it helped her to lose 37 pounds (ie, 16.8kg).2 The theory is that lectins are present in plants in order to defend them against insects and animals and that these lectins can harm humans by binding to the lining of our gut. Dr Gundry has claimed that this leads to inflammation and health issues, such as autoimmune disorders, diabetes, leaky gut syndrome, heart disease and neurodegenerative diseases.3 Lectins are found in a variety of foods (see Table 1). Dr Gundry advises the following: • Peeling and deseeding fruit and vegetables to reduce the lectin content.

• Buying fruit in season so these are eaten ‘at the peak of ripeness’.

• Choosing refined starchy carbohydrates over wholegrain versions.

EXAMINING THE EVIDENCE FOR THE LECTIN-FREE DIET

There is some evidence from animal studies that lectins may bind to the intestinal wall and interact with digestion and the immune system.4,6 It is thought that this may also occur in humans to some degree, as mentioned earlier, but this evidence is not robust.4 For example, lectins can remain undigested in the human 8

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gastrointestinal tract.4 Human antibodies have also been found to form in response to consuming the type of lectins found in bananas and legumes.5,7,8 However, the type of immune response found in these studies is not used as a reliable marker of food intolerance (IgG antibodies), and actually indicates exposure rather than intolerance to specific foods.

Certain types of beans, especially raw red kidney beans, contain lectins, which can be toxic to humans (such as ricin and phytohaemagglutinin). Consuming this type of lectin can lead to vomiting and diarrhoea.9,10 Lectins can also act as ‘anti-nutrients’ by blocking the digestion and absorption of vitamins, minerals and other nutrients.3,11 Fortunately, soaking and boiling beans before eating them significantly reduces the level of lectins present and weakens their binding ability, rendering them safe to consume.11,12 The process of canning beans has also been seen to reduce the lectin content further.13 In vitro studies have found that mixing wheatgerm (containing lectins) with human blood cells can cause inflammation.2 But when human studies have been carried out in a way which is more similar to real life (ie, wheatgerm is cooked and then digested), consuming wholegrain wheat products is seen to actually reduce inflammation.2,14,15 Despite dramatic claims about the lectin-free diet, there is no direct evidence that this boosts weight loss, or reduces disease risk in humans. Any improvement that occurs whilst on this diet is likely to be related to other dietary factors. For instance, reduction of gut issues may be related to a reduced intake

DIET TRENDS Table 1: Foods containing lectins3-5 Beans, lentils, chickpeas and peas

Peanuts (and peanut-based products)

All grains, especially wheat, rice and corn and products made from these like bread and cake

Dairy products (Dr Gundry encourages A2 milk instead)

Most types of fruit, especially goji berries, cherries and blackberries (seasonal fruit is thought to be lower in lectins)

Meat from corn-fed cattle (Dr Gundry recommends grass-fed meat instead)

Most types of vegetables, especially butternut squash, pumpkin and ‘nightshade vegetables’ like: peppers, tomatoes, aubergine and potatoes

Oregano, parsley, peppermint nutmeg and spices

of FODMAPs, as many lectin-containing foods are also high in FODMAPs. Similarly, weight loss may be related to a reduction in calories, as the lectin-free diet is very restrictive. However, there are more targeted and established ways to achieve these benefits without using this diet.

Furthermore, as with all restrictive diets, there are health risks to consider related to this.

Some people may be allergic to lectins, such as the proteins found in certain types of beans and nuts.9 But, this is a medical condition that should be diagnosed by a doctor. Therefore, there is no need for the general public to avoid lectins for this reason. In fact, avoiding possible allergenic food may increase the risk of food allergy, especially in early life (although medical support is needed when considering introducing certain allergenic foods to infants who have a high risk of food allergy).16,17 There is also evidence related to possible health benefits of lectins. For example, the fact that lectins can survive digestion may be beneficial for the gut and gut-mediated metabolic and immune responses.18 A review from 2016 concluded that the lectins found in mushrooms may have anti-cancer properties and ‘these biomolecules [may have potential as] novel antitumor drugs in the near future’.19 RISKS RELATED TO THE LECTIN-FREE DIET

This diet limits a number of foods which are known to be really good for us. Firstly, there is very good evidence that consuming plenty of fruit and vegetables (especially vegetables) is associated with a reduced risk of heart disease, cancer and all-cause mortality.20 However, the lectin-free diet specifically limits a number of fruit and vegetables which are known to be beneficial, such as the possible anti-cancer activity of mushroom lectins as discussed above. Tomatoes

and blackberries have also been seen to reduce inflammation and the risk of chronic diseases.21,22 Similarly, consuming cooked beans and pulses can help to reduce inflammation and improve weight loss and metabolic health.23,24 These are also a good source of plant-based protein, fibre, B vitamins and a number of minerals. The lectinfree diet also limits wholegrains, although these are highly nutritious and a great source of fibre.

There is good evidence that a high intake of wholegrains is linked to a reduced risk of heart disease, Type 2 diabetes, bowel cancer and allcause mortality.25,27 Beans, wholegrains and certain vegetables are also prebiotics that feed our healthy gut bacteria and contribute to better gut health.28 Moreover, research is emerging that good gut health plays an important role in overall health by reducing the risk of chronic disease and improving metabolism and immunity.27 These foods are also high in fibre and low in calories, so there is a chance that these may be replaced with higher calorie options.

Furthermore, as with all restrictive diets, this runs the risk of creating an unhealthy relationship with food, or triggering disordered eating.

CONCLUSION

From a food safety point of view, we should soak then cook dried beans well before eating, as they can contain a type of lectin which is toxic to humans. But beyond this, there is no good evidence that we should be reducing our intake of all foods that contain lectins. In fact, these tend to be really nutritious plant-based foods, so cutting these out could lead to a number of health issues. Overall, there is much more evidence that foods deemed to be high in lectins are good for us, as compared with sparse evidence that these may cause harm. www.NHDmag.com November 2019 - Issue 149

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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

SPORTS NUTRITION

Sports Nutrition is thought to be the foundation of athletic success, in achieving fitness goals and optimising performance, training and physique. Here, Farihah looks at how sports nutrition can differ from everyday basic nutrition needs.

Back in March, I looked at the pitfalls of overhydration in marathon runners and other sportspeople, exercise-associated hyponatremia (EAH), as well as discussed the physical conditions which require sports drinks to be taken.14 The niche of sports nutrition has arguably blown up in recent years, with ‘health and wellness’ bloggers cropping up on every corner of social media. Suddenly, there is protein added to everything (so it must be healthy…) and ‘macros’ are tracked with military discipline by zealous gym-goers. But, what do sportspeople and athletes really need to be mindful of and how does their dietary management differ from day-today nutrition?

ENERGY OUT, ENERGY IN . . .

Although sports nutrition is a vital consideration for athletes in order to optimise performance in a certain sport, a good chunk of the population would agree that their own fitness goals are often to lose weight or get a bit fitter, whether this is for health or aesthetic reasons. The epitome of exercise and weight loss is the energy deficit equation.1 Though there are a myriad of factors influencing a person’s ability to gain and lose weight, in the simplest terms, it boils down to one formula: to expend more energy than you gain. This could either be achieved via exercising and burning more calories than you are

Farihah Choudhury Masters Student, London School of Hygiene and Tropical Medicine

eating, or by eating fewer calories than you would do typically, so that your body metabolises your store of fat for energy. A combination of diet change and regular physical activity is most sustainable for long-term health, not just for weight loss or gain.2 Undoubtedly, weight loss and healthfulness are strongly individual and what works specifically for one person will rarely work for another.

So, whilst energy deficit equations are a good way for an individual to understand the ultimate process of weight loss, the complexities around it for each individual need to be addressed fundamentally when working out exercise and diet plans.

Unless you are actively trying to lose weight, when you are performing vigorous exercise, it is vital to re-energise correctly and replace lost energy and fluids, otherwise you risk losing weight unwillingly. In athletes, Relative Energy Deficiency in Sports (RED-S) is characterised by excessive exercise and/ or insufficient caloric intake, which can, in turn, affect physiological processes, metabolism, mental health, bone health and more.3

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: https://www. nhdmag.com/ references.html

CARB-LOADING

Many people will be familiar with the concept of ‘carb-loading’ prior to www.NHDmag.com November 2019 - Issue 149

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COVER STORY exercising, whether this be a half marathon or a weights session at the gym. Carbohydrates are metabolised as glycogen in the muscles and liver and will provide gradual energy release to fuel energy exertion when performing physical exercise. Carbohydrates are mobilised by the body first and glycogen stores are limited, so it is important to replenish this store prior to exercise.4 Higher carbohydrate intake is more important to those who partake in endurance exercise, such as long-distance running and football.

Though there may be different motivations, some people opt to exercise fasted, whilst others like to eat before exercising, particularly if exercising first thing in the morning. If the fitness goal is weight loss, there is some evidence to suggest that exercising in the fasted state encourages the body to metabolise fat as fuel, but there is no conclusive evidence to confirm this.5 Others may choose not to eat before going to the gym, simply because of time constraints or personal preference.

PROTEIN-PACKED SNACKS

Adequate protein consumption is vital for muscle repair and growth following exercise.

It is recommended that on average, adults in the UK should consume 0.75g of protein for every kilogram of bodyweight per day.4 This may fluctuate slightly depending on how much physical exercise you do. But how much protein is too much protein?

A bizarre offshoot of the health and wellness industry dominating the First World is the marketing ploy of adding protein to typically non-protein yielding foods, such as chocolate bars or crisps, or pointedly signalling consumers to protein that already largely constitutes that food product, eg, in a packet of beef jerky. Part of this stems from a villainisation or misunderstanding of carbohydrates and fats – the trust in these two macronutrients fluctuates depending on which fitness influencer, celebrity or animal study is in vogue at the time. Ergo, we are left with protein, which is generally seen as ‘clean’ and unproblematic and, thus, it is ‘healthy’.

Part of this, of course, comes from a basic understanding that excess protein is not stored 12

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in the body so cannot contribute to unhealthy weight gain.

Alongside protein-fortified snacks, protein powder supplements have also been getting plenty of press in recent years, though mostly this is unnecessary; people in the UK consume more protein in their diets than the recommended guideline daily amount.4 Protein shakes can be useful, however, as a quick source of protein to ingest during and after exercising to aid muscle tissue repair and regeneration. They are sometimes used as meal replacements too, for those who are unable to ingest solid food. Food products specifically claiming to enhance sporting performance and promote athletic physique must be approached with caution, however, as this industry is generally unregulated.

PROTEIN DEFICIENCY AND EXCESS

Protein deficiency is extremely uncommon in developed countries, and it is a myth that there is not enough bioavailable protein in vegan and vegetarian diets, as the body is capable of taking incomplete amino acids and making them ‘complete’ via the amino acid recycling mechanism.6 The most severe type of protein deficiency is called kwashiorkor, and is prevalent in countries affected by war and famine.

Even for those looking to build or maintain muscle, though it is important to maintain adequate protein intake to allow for growth and repair of muscle, excess protein intake is mobilised by the body into energy and will not contribute to further muscle growth. 20g of high-quality protein has been shown to be the optimum protein intake for muscle protein synthesis following exercise.4 Plant-based protein and animal-based protein is absorbed differentially by the gut, which can affect net protein intake. Animal protein is generally easier to absorb than plant protein for humans, though this does not pose a compromising issue for those on a plant-based diet, as is demonstrated by vegan bodybuilders!7 After a certain point, excess protein cannot be used for muscle growth and repair and, instead, is used as energy. Excessive protein intake has been linked to renal issues and

COVER STORY

Chemically, sports drinks are fortified with electrolytes and sugar to replace lost electrolytes and to top up energy, at the same time keeping the drinker hydrated.

heightened cancer risk, but a systematic review by Pedersen et al on the effects of excess protein intake has shown that evidence for this relationship is inconclusive.8 There is a clear gap in the literature regarding overconsumption of protein.

Apparently, for optimal muscle tissue repair and subsequent muscle growth, protein should be consumed within the hour following exercise.9,10 This narrow post-workout anabolic window has been brought into question, however, so this recommendation should be taken with a pinch of salt.11 It has been suggested that this â&#x20AC;&#x2DC;window of opportunityâ&#x20AC;&#x2122; may span longer than just an hour and, again, this may be different for each individual.

SPORTS DRINKS

Around a decade ago, there was a sports drinks craze whereby drinks such as Lucozade and Gatorade were esteemed as the optimal drink for athletes, as well as for the average citizen.

Chemically, sports drinks are fortified with electrolytes and sugar to replace lost electrolytes and to top up energy, at the same time keeping the drinker hydrated. Left unchecked, lost electrolytes can lead to mild or serious hyponatremia (low sodium/water

poisoning). However, it has been suggested that only those who exercise for 90 minutes or more consecutively, and/or are drinking excessive amounts of water, need to consider taking sports drinks.12 It has been estimated that 1/6th of marathon runners develop mild hyponatremia,13 which can be remedied by drinking sports beverages, or marginally reducing the amount of water ingested.

SUMMARY

Sports nutrition is a complex niche, where exercise goals are very much driven by the individualâ&#x20AC;&#x2122;s motivations for exercise and their dispositions to weight loss, muscle gain and several other factors. Nutrition in sports differs from day-to-day nutrition to optimise the outcomes of fitness goals and so, to really maximise performance, diet is key, alongside picking exercise regimes that work for each individual.

Sports dietitians and personal trainers can collaborate in this respect, to formulate complementary diet and exercise plans to help individuals achieve their goals. On a public health level too, dietitians can help to inform exercise recommendations for the general population. www.NHDmag.com November 2019 - Issue 149

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TAKE A FRESH LOOK AT MANAGING CROHN’S DISEASE

ModuLife is based on a clinically proven solution for the management of Crohn’s Disease (CD) through food and specialist nutrition.1-3 Visit www.mymodulife.com to learn more or ask your Nestlé Health Science representive about enrolling on our free training programme.

THERE’S NO OTHER CD SOLUTION LIKE IT FOR HEALTHCARE PROFESSIONALS ONLY References: 1. Sigall Boneh R, et al. Inflamm Bowel Dis. 2014 Aug;20(8):1353-1360 2. Sigall Boneh R et al. J Crohn’s Colitis. 2017 Oct 1;11(10):1205-1212. 3. Levine A, et al. Gut 2018;67:1726-1738 Modulen IBD is a Food for Special Medical Purposes for the dietary management of Crohn’s disease. For use under Medical Supervision.

Nestlé Health Science UK

CONDITIONS & DISORDERS

CROHN’S DISEASE AND ENTERAL NUTRITION This article reports on the use of enteral nutrition (EN) for remission and looks at new research into partial enteral nutrition (PEN) and the Crohn’s Disease Exclusion Diet (CDED).

Crohn’s disease is a form of inflammatory bowel disease (IBD), alongside ulcerative colitis. Both are long-term conditions that cause inflammation of the gut. It is unclear what causes IBD, but it is thought to be a combination of genetics and individual immune systems.

Crohn’s disease can result in inflammation anywhere in the digestive tract, from the mouth to the anus, but is most commonly seen in the in small intestine or colon.1 Smoking is linked to an increased risk of developing Crohn’s disease.2 Symptoms can be unpleasant and include abdominal pain, loose and frequent bowel movements, fatigue and weight loss as a result of malabsorption.

ENTERAL NUTRITION (EN)

Crohn’s disease is increasing in incidence worldwide.3 Dietary intervention is deemed important, as many of the drugs used in treating the condition involve immune suppression and carry associated risks of infections, or, in some cases, malignancy.4 Nevertheless, overall, there is a lack of evidence looking into diets specific to Crohn’s disease, particularly in adults. The use of EN – a liquid-only diet – for the management of Crohn’s disease was first described in the 1970s5 and it is known today, that EN given either orally or via a nasogastric (NG) tube may be used during a flare up.

Exclusive EN has been seen to improve the symptoms of Crohn’s disease as it gives the bowel ‘rest’ and allows for mucosal healing. It has also been shown to reduce

Rebecca Gasche Specialist Dietitian, Countess of Chester Hospital NHS Trust

the production of bacterial metabolites within two weeks and reduce the bacterial coating with immunoglobulin.6 EN is usually taken for six to eight weeks and elemental or polymeric oral nutritional supplements or feeds can be used.

DIETARY MANAGEMENT

For patients who experience stricturing Crohn’s (narrowing of the bowel), the ESPEN guidelines recommend that a diet with modified texture or EN may be advised.7 The guidelines go on to say that for patients with radiologically identified but asymptomatic stenosis of the intestine, it is common to recommend a diet low in fibre. However, there is no robust data to support this apparently logical approach. When symptoms are present, it may be necessary to adapt the diet to one of soft consistency, perhaps predominantly of nutritious fluids. There is also some evidence for the use of a low residue (low-fibre) diet if there are strictures as a result of Crohn’s disease.7 A literature review by Rhodes and Richman8 reported that indirect evidence for diet and IBD suggests that Crohn’s patients should have a diet that is low in animal fat, avoid foods that are high in insoluble fibre and avoid processed fatty foods. Supplementary vitamin D should be considered and dairy products if tolerated can be consumed to help ensure adequate calcium intakes. There is weak evidence that olive oil might be protective and evidence to suggest that strict

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: https://www. nhdmag.com/ references.html

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CONDITIONS & DISORDERS avoidance of dairy products and/or lactose is not justified. The published guidance provided by professional bodies varies considerably between different sources and is often based on consensus of opinion rather than evidence.8 Further research into this field is needed.

The ESPEN guidelines7 report that the use of EN for the treatment of Crohn’s disease in adults is generally weaker than that of paediatric studies, hence most centres will continue to use steroids (or biologicals) as first-line therapy unless these agents are actively contraindicated.

However, patient and disease characteristics also contribute to therapeutic management decisions and these may make EN therapy a first-line option in selected cases of adults with a Crohn’s disease flareup.

COCHRANE REVIEW

An updated Cochrane review9 (a systematic review of the evidence base) from 2018 looked at whether EN can benefit Crohn’s patients more than corticosteroids. It concluded that there was very low-quality evidence to suggest that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active Crohn’s disease. The review also found that there was very low-quality evidence to suggest that EN may be more effective than steroids for induction of remission in children with active Crohn’s disease.

When looking at protein composition of feeds for EN, the review found that it does not appear to influence the effectiveness of EN for the treatment of active Crohn’s disease. The review did highlight the fact that many adults and children require NG tube feeding due to the palatability of supplements used and, therefore, EN should be considered in patients who can either comply with NG tube feeding or perceive the nutritional supplements to be palatable, or when steroid side effects are not tolerated, or better avoided. The review advised that more products from industry should be developed to make palatable polymeric formulations, so that they can be delivered without use of a NG, as this may lead to increased patient adherence with this therapy.

As highlighted in the Cochrane review,9 the use of EN to achieve remission in children with 16

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Crohn’s is often used as first-line treatment, rather than the use of steroids.3 However, a strict compliance is required and NG tube feeding is often used to overcome this. Besides formulating more palatable nutritional supplements, is there another way to overcome this?

A NEW APPROACH?

This year, there has been new research looking into the use of partial enteral nutrition (PEN) and the Crohn’s Disease Exclusion Diet (CDED). The study by Levine et al was published in August 2019, and involved a 12-week trial in children with moderate-mild Crohn’s disease.3 Prior to this study, additional research by Levine et al10 suggested that diet may impact on the pathogenesis of Crohn’s disease, in particular looking at the alteration of microbiome and a breakdown in barrier function with defective bacterial clearance. This particular study from 2018 suggested that a different approach to Crohn’s therapy could be considered, targeting microbiome as this may play a role in the generation of inflammation.10 The changes and westernisation of foods may also play a role in effecting the microbiome, and previous studies looking at PEN with diets of equal part fat, protein and carbohydrate, showed this was not effective in inducing remission.11 The CDED diet had previously shown a promising ability to induce remission and decrease inflammation in case series in both children and adults with CD,12 however, the Levine et al (2019) research was the first study to compare CDED combined with PEN against complete EN.3 This study3 randomly split the groups into either receiving a PEN diet, using Nestle’s product Modulen IBD, alongside a Crohn’s disease exclusion diet (CDED), versus a complete EN diet. The CDED diet is a wholefood diet designed to reduce exposure to the dietary components that are thought to negatively affect the microbiome, intestinal barrier and intestinal immunity. Those on the CDED diet had six weeks of Modulen as PEN and diet making up 50% calories each, followed by 75% diet and 25% PEN in weeks 7-12. Those on complete EN had Modulen IBD as a sole source of nutrition for six weeks, followed by free diet and PEN contributing to 25% calories in weeks 7-12.3

CONDITIONS & DISORDERS The foods allowed in the first six weeks of the CDED diet included protein sources such as egg, chicken, carbohydrates in white rice and certain fruits and vegetables such as one slice of melon, fresh strawberries and carrots. In weeks 6-12 more varieties of fruits, vegetables and higher fibre/fat foods were reintroduced, with foods more likely to trigger symptoms, such as wheat, lactose and artificial sweeteners, being avoided until the full 12 weeks was completed.

The results3 showed that both diets were associated with high and comparable rates of clinical remission and both had a significant and similar decrease in inflammation by week 6, and both groups had similar changes in the microbiome induced by diet by week 6. However, the biggest differences were noted in weeks 6-12.

The two groups differed from week 6 (as the completely EN group transitioned to PEN with gradual return to free diet), as sustained remission, maintenance of remission and normal CRP (an inflammatory marker) remission at week 12 were significantly better in the CDED/PEN treated group. Faecal calprotectin (a stool sample looking

for inflammation) was actually noted to increase in weeks 6-12 in those on the total EN group, whereas it decreased in those of CDED and PEN. This data suggests that the foods being avoided in the CDED do in fact play a role in remission of Crohn’s disease, and that a structured approach to reintroducing diet should be considered.3 Despite this trial being looked at only in children, the CDED diet is also being recommended in adults, with the hope that it will improve compliance.

It is worth noting that Nestlé Health Science funded the above study and have now launched Modulife as a result, a new program ran by Nestlé using the CDED and PEN approach. It provides an online training course for healthcare professionals, as well as support for patients in the form of an app that allows patients to track their diet, contact healthcare professionals, look up recipes, etc. I feel this is a really good resource for patients, as any dietary treatment can be daunting and having support available could be of great benefit.13

Coming in the next issue Dec 2019/Jan 2020 www.NHDmag.com

• Premature infant feeding • Plant-based diets

• Paediatric diabetes

• Nasogastric tube feeding

• ERAS wound care

• Constipation

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SKILLS & LEARNING

Sarah Lumley RD County Durham and Darlington NHS Foundation Trust and Freelance Sarah has a wide range of experiences as a nutrition expert in both acute and community settings. She is keen to share her enthusiasm for food and personal development.

REFERENCES Please visit: https://www. nhdmag.com/ references.html

CLINICAL SUPERVISION AND CONTINUOUS PROFESSIONAL DEVELOPMENT It pays to take time to consider the importance of clinical supervision and CPD, planning its implementation to maximise the success of any dietetic venture. This article looks at the key components of clinical supervision.

Continuing education into adulthood, with an emphasis on lifelong learning, has been an area of interest within healthcare for many years, but the acknowledgement of it grew with founding of the American Dietetic Association (ADA) in 1918.1 Today, continuous professional development (CPD), of which clinical supervision is a form, is still an important aspect of any dietitian’s working life. An effective learning tool, clinical supervision can take many forms to fit each individual person, speciality, or department and can evoke positive change and progress.

Furthermore, medical and pharmaceutical advances mean presenting patients are more complex, with more combinations of comorbidities that need to be prioritised. The difficulty for dietitians comes in ensuring that practice is kept up to date, which can be difficult when faced with the time pressures of workload, or with the individual nature of being a freelancer. Clinical supervision can be a rewarding activity to partake in, for the opportunities it provides in enhancing learning and, ultimately, improving patient care.4

THE IMPORTANCE OF CLINICAL SUPERVISION

The definition of clinical supervision can be traced back to the Department of Health and although the original document is difficult to find, it has been quoted or adapted many times by healthcare authoritative bodies, indicating that clinical supervision is an ‘exchange between practicing professionals’ and often relies on the experience of those individuals and the need for trust between them.5 Within CPD, there is an emphasis on autonomy, which could be interpreted as each individual needing to complete their learning within isolation.2 This is not the case, especially within clinical supervision, which encourages the development of meaningful working relationships between colleagues.2

The work of a dietitian is everchanging, due to new research studies being completed, guidelines being reviewed and advances in medicine and pharmaceuticals.2 Social media advances have also meant that service users are exposed to more nutritional research and advice, with differing levels of evidence behind them. It is important that the dietitian has an understanding of the evidence behind any nutritional claims and is supporting their practice with a solid evidence base. This is a key component within the Health and Care Professions Council (HCPC) guidance for dietitians.3 18

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WHAT EXACTLY DOES CLINICAL SUPERVISION ENTAIL?

SKILLS & LEARNING The ‘exchange’ between these colleagues is quite open to interpretation. There are many activities which could be considered part of clinical supervision, as the BDA highlights.6 Each interpretation of what clinical supervision will look like will depend on those who are being served by the session. Like each department, sessions will be tailored depending on the resources available, the expectations of staff and the evaluation of sessions over time.2 It is important, however, that clinical supervision is worthwhile and fulfilling, from a professional and educational perspective.

Therefore, there are key components which should be included in each type or style of clinical supervision.

KEY COMPONENTS OF CLINICAL SUPERVISION

Trusting relationships Clinical supervision, the discussion of current practice or of service user care, could feel quite personal to the individual whose work is being discussed. It is, therefore, crucial that a trusting, working relationship is built.2 There is a need for support within these working relationships, to allow for open and honest discussion to take place.7 A collaborative approach Clinical supervision is for the benefit of everyone involved, the organisation and the service users.2 In order for those involved to get the most out of it, they should be involved in the development and planning of the sessions, including some leadership on topics being discussed.8 It is also important to acknowledge the learning styles which suit each individual, so the session is effective for all involved.2 Focus Taking time away from direct clinical duties to complete clinical supervision sessions can be difficult, especially if the benefit of clinical supervision is not tangible. Having an action plan to take away from each clinical supervision session ensures that those involved have a focus.2 This could be an individual or team action, in order to develop their understanding, or practice, or service users’ satisfaction, or experience.

WHERE CAN CLINICAL SUPERVISION BE SITUATED?

The BDA list of activities considered suitable as CPD includes many that could be considered clinical supervision.6 There is no one size fits all approach, with ideas ranging from the formal and structured, to more informal and freeform sessions. More formal supervision could include a presentation of a service user’s dietetic care by a colleague or case studies.6 Less formal sessions could include work shadowing and coaching.6 Clinical supervision models can work on a one-to-one basis, or in groups.2 Groups can be of one discipline or several, as clinical supervision and CPD extend to all Allied Health Professionals (AHPs).9 Multidisciplinary team (MDT) working is vital in caring for service users, so there is no reason not to include MDT working within clinical supervision. It could be argued that clinical supervision needs to involve all of those working within a service, in order to allow for true understanding and meaningful development.9 By doing so, learning is a shared commitment and service development can be driven by all professions working alongside one another.4 The BDA idea of clinical supervision stretches as far as visiting other departments and reporting back to your own – suggesting cross working can support dietetic advancement and actively encouraging team working.6 OVERCOMING THE CHALLENGES OF CLINICAL SUPERVISION

When implementing any new aspect into your professional life, there can be a series of barriers to overcome. It is important to see these as challenges, which can be manoeuvred, but which may shape the way you choose to complete your clinical supervision, so it is meaningful for you.

Lack of time A lack of time can often be cited as a challenge for healthcare professionals, when trying to alter practice. When considering developing clinical supervision sessions, planning is key.2 This remains crucial when sustaining clinical supervision sessions too, ensuring time is regularly planned in, as part of your working www.NHDmag.com November 2019 - Issue 149

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SKILLS & LEARNING week or month. Also, inclusion of your employer within your plans will likely benefit you, as they may be able to support your request for clinical supervision, given that the benefits of CPD stretch beyond the individual to the wider team, employer and service users.4 Lone working Much of the literature surrounding clinical supervision can be easily transferred to dietitians working within the public sector, where large teams are often working together.

It can be more difficult if the dietitian is working freelance, or is the sole dietitian within their team. It is important to remember that clinical supervision can cross the boundaries of individual professions.9 Depending on your area of work, there may be more benefit for yourself in working with other AHPs, for instance a sports team dietitian working alongside the same team’s physiotherapist, or medical professional.

Where there is less of a team dynamic, there are the options of online resources for individuals to focus on. Alternatively, social media advancements mean there are groups for different specialisms within dietetics, where mentoring and clinical supervision support is available, including freelance dietetics as a specialism within itself.10 Trust Trust has already been mentioned as a key component of clinical supervision success, but it can be difficult to develop, especially if the supervisor and supervisee(s) are unknown to one another.11 In order to establish a good professional relationship, creation of a contract, whereby each party agrees to and is bound by a set of ground

C

rules, can help in the primary stages. This creates a boundary, around which each party can become accustomed to the other and build a deeper trusting relationship as appropriate.11 CONCLUSION

Clinical supervision should be embraced by all dietitians, as a lasting aspect within our professional roles. It can be used to motivate and drive us to improve ourselves and our services for our users, creating a sense of job satisfaction and pride. As our profession develops, so do our clinical supervision needs, highlighting that whilst there are key components to include, we all have different professional barriers to overcome.

Thus, our clinical supervision will take very different forms, to ensure it is effective for us all.

The words of E Neige Todhunter, ADA President 1957-58, still ring true today: “Within dietetics, there is a need to read, think and do”.1 Together we can read the literature, critically think about what is written and the implications for practice and take action, changing our practice together, to improve the services we offer and the experiences of our healthcare users.

More information There are a lot of resources available to support you in starting or developing your own clinical supervision sessions. These include the BDA and other AHP professional bodies, the HCPC, Effective Practitioner and The Interprofessional CPD and Lifelong Learning UK Working Group. There may be existing inhouse training opportunities or resources you can utilise too, so consider speaking with your colleagues, management, or development department, to support you in setting up clinical supervision in your workplace.

P

D

Continuing professional development To view our latest NHD CPD eARTICLE please visit NHDmag.com 20

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PAEDIATRIC

WEANING AN INFANT WITH COW’S MILK PROTEIN ALLERGY - Part 2 Cow’s milk protein allergy (CMPA) is the most common food allergy in babies and young children and the management of CMPA is an ever-evolving landscape. In Part 2 of this article, Paula takes a look at complementary feeding and the introduction of allergenic foods, highlighting micronutrient inadequacy and its management.

There are no official UK guidelines for weaning an infant with CMPA. Weaning should commence when a baby is showing all the signs of developmental readiness, which is usually around six months (but not before 17 weeks) of age.

Signs of developmental readiness include: • the baby can maintain a sitting position and can hold its head steady; • the baby can pick up food and navigate it to its mouth; • the baby can swallow food (look for loss of the tongue thrust reflex).

Introducing solids to a baby who has cow’s milk allergy (CMA) should be the same as for a non-allergic baby, except avoiding all sources of cow’s milk and dairy products. The Food Allergy Specialist Group (FASG) of the BDA recommends starting with green vegetables and root vegetables, potatoes

and rice, as well as iron-rich foods such as chicken, meat and pulses, from six months of age (as iron stores start to run low from six months of age for full-term babies).

INTRODUCTION OF ALLERGENIC FOODS

Common allergenic foods (such as egg, soya, wheat, peanuts* and other nuts*, sesame seeds*, mustard seeds*, celery, fish and shellfish), should not be avoided once a baby is six months old, as long as the baby is not allergic to these foods. Current advice is to introduce all common allergenic foods that a baby is not already allergic to, and which are part of a family’s usual diet, between 6-12 months of age (FASG BDA). *as ground nuts, nut butters, or seed butters for babies and young children.

A sensible and practical approach is to introduce each allergenic food one at a time earlier on in the day, so that the

Table 1: Products available on prescription**

Extensively hydrolysed formulas

Amino acid formulas Soya formula

Brand

Manufacturer

Aptamil Pepti 1 & 2

Nutricia

Nutramigen 1 & 2 with LGG

Mead Johnson (part of RB)

Aptamil Pepti Junior

Nutricia

Similac Alimentum

Abbott

Pregestimil Lipil

Mead Johnson (part of RB)

SMA Althera

Nestlé Health Science

Nutramigen Puramino

Mead Johnson (part of RB)

Neocate range

Nutricia

SMA Alfamino

Nestlé Health Science

SMA Wysoy

Nestlé Health Science

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.

REFERENCES Please visit: https://www. nhdmag.com/ references.html

**For more on appropriate formulas and prescriptions, see Part 1 of Paula’s article in the October issue of NHD. www.NHDmag.com November 2019 - Issue 149

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COW’S MILK ALLERGY

DOESN’T ALWAYS END AT ONE YEAR

TRUST NEOCATE JUNIOR TO SUPPORT HIS NEXT STEP

Request a FREE SAMPLE* direct to your patients today

Neocate Junior Aged 1 - 10 years The unique Amino Acid-based Formula for children with Cow’s Milk Allergy over one year of age.

Best tasting†

Well tolerated‡

Flexible concentration

Excellent compliance‡

Visit: nutriciaproducts.co.uk/samples This information is intended for Healthcare Professionals only.

Neocate Junior is a Food for Special Medical Purposes for the dietary management of Cow’s Milk Allergy, Multiple Food Protein Allergies and other conditions requiring an Amino Acid-based Formula, and must be used under medical supervision after full consideration of all feeding options including breastfeeding. *Product can be provided to patients upon the request of a Healthcare Professional. They are intended for the purpose of professional evaluation only. † Data on file, May 2016 & January 2017 ‡ Clinical data on file, May 2016 Accurate at time of publication, November 2019.

Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ

Table 2: Calcium – UK recommended intake at different ages Age

Calcium per day (mg)

0-12 months

525

1-3 years

350

4-6 years

450

7-10 years

550

11-14 years

800

Breastfeeding mum

1250

infant can be observed for an allergic reaction.

Some sources also recommend starting with a very small amount of the allergenic food and to give increasing amounts over three days to observe for any possible reactions. Once introduced, and if the food is tolerated, an allergenic food should continue to be included in the infant’s diet at least once or twice per week to maintain tolerance to that food.

More detailed information about infant feeding and allergy prevention is available here: www.bsaci.org/about/early-feeding-guidance.

A NOTE ABOUT ECZEMA AND ‘HIGH RISK’ INFANTS

If an infant has a history of severe eczema, they are at higher risk of developing other food allergies, particularly if the eczema appeared within the first few months of life and is persistent and severe, despite treatment with topical steroids and emollients. If this is the case, parents/carers may need more specific advice from a healthcare professional about the timing of introduction of allergenic foods. A skin prick test or specific IgE blood test may be recommended first before introducing egg and peanuts. It is advisable to refer these infants to an allergy clinic early for an assessment and appropriate advice.

MICRONUTRIENT ADEQUACY OF DAIRY-FREE DIETS

Cow’s milk and dairy products are an important source of energy and protein, as well as calcium, iodine, phosphorus, riboflavin, vitamin B12 and vitamin A.1 When considering non-dairy alternative food and drinks for infants and children with CMPA, these micronutrients need to be considered.

Current UK guidelines for the diagnosis and management of CMA recommend the use of a suitable hypoallergenic infant formula until two years of age for infants and children with CMPA.2 Meyer et al have supported this recommendation in a prospective observational study in 2014,3 where they looked at the adequacy of micronutrient intake in 105 children aged four weeks to 16 years of age, diagnosed with food protein induced gastrointestinal allergy. They assessed the 54 children <2 years of age separately and found that 74% of those not taking a hydrolysed formula (HF) had deficient micronutrient intakes, compared with 17% of those taking a HF. It should be noted that there was no control group in this study and the group under two years of age not taking an HF consisted of only seven children, compared to 47 children who were taking an HF. This discrepancy is due to the fact that an HF is recommended until two years of age in UK national guidelines.2 Calcium As dairy products are the principal source of calcium, a paediatric dietitian should assess the calcium intake of each infant and child with CMPA and appropriate advice given.

Good sources of non-dairy calcium include nuts (ground nuts/nut butters for infants), fish with soft edible bones, tofu, pulses, seeds and calcium-fortified cereals2 (see Table 2). A study

by Ambroszkiewicz et al in 2014,4 reported that children with CMPA showed some changes in biochemical bone metabolism markers and they concluded that calcium and vitamin D status should be monitored and dietary intake assessed for children on elimination diets. www.NHDmag.com November 2019 - Issue 149

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THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best for babies

The importance of palatability when choosing an extensively hydrolysed formula for the dietary management of cows’ milk allergy in formula fed infants TASTE PREFERENCES Clinical guidelines recognise palatability as a key factor in EHF choice1–3 Infants may be prescribed their first EHF after taste preferences have developed4,5

SUPPORTING GROWTH AND DEVELOPMENT Adequate consumption of EHF is paramount to achieve nutritional requirements8,9

PRESCRIPTION ADHERENCE Bitter EHFs are often strongly rejected after 4 months of age2 Parents often report that their child refuses EHF due to unpleasant taste6

IMPROVING COMPLIANCE In a newly published study, most HCPs agree that a palatable EHF could lead to non-rejection and more content infants and families7

SUPPORTING HEALTHCARE OUTCOMES Most HCPs agree that a palatable EHF could lead to reduced repeat visits, and decreased wastage and healthcare costs7

Aptamil Pepti is the UK’s most palatable EHF In a newly published study a panel of 100 dietitians and GPs ranked Aptamil Pepti as the most palatable EHF formula7

References: 1. Venter C, et al. Clin Transl Allergy 2013;3(1):23. 2. Luyt D, et al. Clin Exp Allergy 2014;44(5):642–672. 3. Walsh J, et al. Br J Gen Pract 2014;64(618):48–49. 4. Sladkevicius E, et al. J Med Econ 2010;13(1):119–128. 5. Mennella JA, et al. Am J Clin Nutr 2011;93(5):1019–1024. 6. Vandenplas Y, et al. Eur J Pediatr 2014;173(9):1209-1216. 7. Maslin K, et al. Pediatr Allergy Immunol 2018;29(8):857–862. 8. Maslin K, et al. Clin Transl Allergy 2016;6:20.

9. Flammarion S, et al. Pediatr Allergy Immunol 2011;22(2):161–165.

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

19-071. Date of prep: October 2019. © Danone Nutricia Early Life Nutrition 2019

PAEDIATRIC Table 3: Non-dairy sources of calcium Product Calcium-fortified products Hypoallergenic infant formula, eg, Nutramigen with LGG, Aptamil Pepti 1, Alimentum, Neocate LCP, Neocate Syneo, Nutramigen Puramino, SMA Alfamino Hypoallergenic follow-on formula (from six months of age), eg, Nutramigen 2, Aptamil Pepti 2, Neocate Junior (only from 1 year +) Wysoy (soya infant formula) Calcium-enriched milk alternatives, eg, soya, oat, nut, coconut ‘Extra’ calcium-fortified milk alternatives, eg, Califia Almond, Koko coconut super milk Calcium-fortified cheddar cheese alternatives, eg, Koko cheddar Tesco free-from cheddar Calcium-fortified soft cheese alternatives Koko cream cheese Tesco free-from soft cheese Calcium-fortified soya or coconut yoghurt, desserts, eg, Alpro, Oatly crème fraiche, supermarket own brands Calcium-fortified hot oat cereal, eg, Ready Brek, supermarket own brands Calcium-fortified cereals, eg, Rice Krispies, Cheerios, Alphabites multigrain cereal Calcium-fortified breads Hovis Best of Both Kingsmill 50/50 Vitamin Boost Soya bean curd (tofu) – ONLY if set with calcium chloride (E509), or calcium sulphate (E516) - not Nigari Non-fortified products Sardines (with soft bones) Pilchards (with soft bones) Tinned salmon (with soft bones)

Quantity

Calcium (mg)

100ml

47-90

100ml

60-95

100ml

67

100ml

120

100ml

170

30g 30g

220 45

30g 30g

60 45

100g

96-160

15g (1 tbsp dry cereal)

200

30g

136-174

1 slice 1 slice

191 150

60g

200

½ tin (60g)

260

60g

150

60g

250

White bread

1 slice

50

Wholemeal bread

1 slice

27

Pitta bread/chapatti

65g

60

Orange

1 medium

75

Broccoli

2 spears (85g)

34

Okra

5 okra fingers

120

Kale

20g

30

(Credit: Adapted from BDA Food Allergy Specialist Group - Cow’s milk free diet for infants and children 2019)

Please note: Some foods, such as spinach, beans, dried fruits, seeds and nuts, also contain calcium, but it is not absorbed very well, as they contain phytates or oxalates which decrease the absorption of calcium. They are still nutritious foods to include, but should not be relied upon as the main source of calcium in the diet.

Vitamin D Lower vitamin D levels have been reported in children with CMPA, especially those who are exclusively or predominantly breastfed.5 The current UK Department of Health and Social Care guidelines state that all children under the age of five years, except those receiving 500ml or www.NHDmag.com November 2019 - Issue 149

25

PAEDIATRIC Table 4: Iodine intake – WHO recommendations Age

Iodine/day (μg)

0-5 years

90

6-12 years

120

Adults and children over 12 years

150

Pregnancy

250

Breastfeeding mums

250

more of infant formula, should receive a vitamin D supplement of 10 micrograms per day all year round. Pregnant and breastfeeding women should also take a vitamin D supplement of 10 micrograms per day.6 Iodine Cow’s milk and dairy products are a significant source of iodine and iodine deficiency has been described in children under two years of age with CMPA.7 This study reported a high prevalence of iodine deficiency in children with CMPA, which was particularly pronounced in exclusively breastfed infants. It is important that the diets of infants and breastfeeding mothers avoiding dairy products, contain other iodine rich foods such as white fish. If the infant (or breastfeeding mum) is also allergic to fish, then an iodine supplement should be considered. Table 4 shows how much iodine is needed for each age group, according to the WHO. Many calcium-fortified non-dairy alternatives to cow’s milk are now also fortified with iodine (as well as calcium and vitamins) and these can be an additional useful source of iodine in dairy-free diets. Examples of plant-based dairy alternative drinks that are fortified with iodine (as well as calcium and vitamins) include: • Alpro soya growing up drink 1-3 years+ • Koko ‘super’ coconut drink • ASDA oat-based drink • All M&S plant-based drinks are fortified with iodine (as well as calcium and vitamins) • Oatly are due to start enriching their oat milk range with iodine later in 2019 at a level of 22.5 micrograms iodine per 100ml See the BDA fact sheet on iodine for further information at: www.bda.uk.com/foodfacts/ Iodine.pdf.

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REINTRODUCTION OF COW’S MILK PROTEIN

There is a tendency for all types of CMA to resolve during childhood, but how rapidly this occurs is highly variable and, therefore, the timing and appropriateness of milk reintroduction should be individually assessed.2 There is no ideal time for testing for development of tolerance, but it is generally accepted that infants with a proven CMPA should remain on a cow’s milk proteinfree diet until 9-12 months of age, or for at least six months (after diagnosis) before attempting to reintroduce cow’s milk into their diets.8 CMPA resolution rates have been reported to vary from 19% to 97% depending on the country and whether the CMPA was IgE-mediated or non-IgE-mediated.9 Non-IgE-mediated allergy is reported to resolve quicker than IgE-mediated allergy.10 Clinical and laboratory indices can both be used to guide reintroduction.2 Clinical indices associated with persistence of CMPA include a history of severe reactions, the presence of other food allergies, asthma, rhinitis and a SPT wheal size >5mm at diagnosis.10-12 As a child develops oral tolerance to cow’s milk protein, a reduction in sIgE and SPT wheal size are seen over time.2,12 Attempts have been made to quantify by how much specific cow’s milk IgE would need to decrease before oral tolerance is seen.12-14 However, an exact percentage decrease cannot be quantified and it can only be said that a ‘substantial reduction’ in sIgE levels over time is associated with the development of clinical tolerance.2 Children who outgrow their CMA become tolerant to baked milk before fresh milk, due to the fact that baking reduces the allergenicity of the protein, particularly whey proteins.2,8 The ‘milk ladder’ has been developed for the stepwise introduction of baked milk products.8,15 Infants with IgE-mediated CMPA may require a supervised food challenge of cow’s milk protein in hospital, depending on the severity of their reactions and if they develop asthma or not.2 CONCLUSION

Weaning an infant with CMPA is not simple, but it is possible to ensure a nutritionally adequate intake with some careful adjustments to the diet and the use of calcium-fortified alternatives.

Consideration should also be given to other micronutrients, such as vitamin D and iodine.

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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, November 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

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CLINICAL

CHYLE LEAKS: AN OVERVIEW This article discusses the aetiology, diagnosis and treatment of chyle leaks.

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

REFERENCES Please visit: https://www. nhdmag.com/ references.html

Working in district general hospitals, I had not come across anyone with a chyle leak until a recent discharge of a patient from a tertiary centre. The individual was discharged following a complicated post-operative stay from a subtotal oesophagectomy for a distal oesophageal adenocarcinoma. Postoperatively, the individual developed a chylous output from an intercostal drain and the volume was significant so that parenteral nutrition was indicated. When I met this individual, they had a fear of consuming fat due to the information they had been given in hospital. This led me to research chyle leaks, what they are and how they are treated.

Chyle leaks occur due to lymphatic injury which may happen as a result of trauma or surgery. Surgeries for which it may occur could be to the chest, the abdomen, the neck, pancreatic resections, etc.1 Although the incidence of chyle leak post-surgery is low (1%4%), this complication can present significant challenges.2 Although rare, it is well recognised as a complication after oesophageal surgery. Sjoerd et al (2005)8 found an association between a chyle leak developing and the presence of positive lymph nodes.

WHAT IS CHYLE?

Chyle is a milky looking substance due to the presence of fat globules. It is an alkaline fluid that is produced postdigestion of food. Bibby and Maskell (2014)3 report that â&#x20AC;&#x2DC;one litre of chyle contains 200 calories, up to 30g of fat and 30g of protein, as well as electrolytes including potassium, sodium, calcium and phosphate.â&#x20AC;&#x2122; It also contains fat soluble vitamins and lymphocytes.

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Its primary function is immunological, but it also functions to transport long-chain fatty acids, fat soluble vitamins and proteins.3 Two to four litres of chyle are transported from the lymphatic system every day.

The location of injury of the lymph vessels can lead a chyle leak to develop in different ways: chylothorax in the thoracic cavity, chyloperitoneum into the abdomen, chylopericardium around the heart, or as an external draining fistula.17 Chyle leakage is a serious complication, with a reported mortality rate varying from 0-50%.18 DIAGNOSIS, SYMPTOMS AND CONSEQUENCES

Individuals often present with symptoms of dyspnoea, chest pain and/ or tachycardia.2 Diagnosis of a chyle leak is made in the presence of chylomicrons in the draining pleural fluid. If the draining fluid contains >100mg/dL of triglycerides it is considered indicative of a chyle leak.19 Symptoms of chyle leak can include breathlessness in chylothorax, in relation to fluid accumulation.3 Dehydration may occur if the volume of leakage is significant and malnutrition is possible due to the loss of calorie and protein rich fluid. As chyle is key in the immunological response, immunosuppression can occur. Metabolic complications can occur due to the loss of fluid and electrolytes.4 WHERE IS CHYLE MADE?

Chyle is formed in the small intestine and is produced as part of the digestive process of fatty foods. The chyle consisting of lymph and chylomicrons is taken up by the lacteals, a type of

CLINICAL

Chyle is formed in the small intestine and is produced as part of the digestive process of fatty foods.

lymph vessel for distribution within the body.

Chyle eventually drains into the thoracic duct, which is a large lymphatic vessel found on the left side of the torso. If a chyle leak develops, the lymphatic vessels cannot heal. Continuing to consume fats means that chyle continues to be produced and the lymphatic vessels are unable to heal.

Smoke and Delegge (2008)2 report that there are ‘strong feelings among clinicians about the use of bowel rest, parenteral nutrition, or a low-fat enteral formula for the treatment of chyle leak; however, definitive evidence supporting one nutrition therapy over another does not exist.’

MANAGEMENT AND TREATMENT

Reviewing the literature, Octreotide may be used to support chyle leak closure as it reduces gastrointestinal blood flow and gastrointestinal hormone secretion.3 It is also suggested that Orlistat could also be given as an adjunct since it interferes with lipid metabolism in the duodenum and prevents lipid absorption,7 thus decreasing chyle production.

Daily management of chyle leaks includes fluid balance and review of electrolyte levels.5 Removal of fluid with percutaneous aspiration or drainage may be required to reduce symptoms, whilst long-term management is ongoing.3 Reviewing the articles, treatment options can include nutritional, surgical and pharmacological components. Delaney et al (2017)5 report that, ‘following surgery, management of a chyle leak depends on drain output, patient comorbidities, available institutional expertise and surgeon preference’.

They define a chyle leak as low output if <500ml/ day, or high if >500ml/day. Low output drains of <500ml/day are said to be treated effectively with conservative management, but those of a high output are likely to require surgical intervention.6

PHARMACOLOGY

NUTRITION

A nutrition management plan for chyle leaks is considered first-line management, with success rates of 80%.8 Reviewing the evidence, there are different approaches from a dietary perspective.

Steven and Carey (2015)20 reported that there was no significant difference between dietary approaches to treat chyle leaks and the rate in which they resolved.

Campisi et al (2013)9 say that all patients with suspected chyle leaks should be www.NHDmag.com November 2019 - Issue 149

29

CLINICAL transitioned onto a non-fat or low-fat diet.

A fat-free diet would not be nutritionally complete; it would be rather unpalatable and difficult to adhere to, thus potentially contributing to malnutrition. A mediumchain fatty acid (MCFA) containing diet with multivitamin supplementation is suggested to be preferable to a non-fat diet.9 Some chyle leaks have been shown to resolve on a low-fat diet alone.10 A low-fat diet that is high in MCT (medium-chain triglycerides) may be successful in reducing the chyle leak. MCTs passively diffuse from the gastrointestinal tract to the portal system and are absorbed directly into portal circulation rather than being transported in lymph.3 As they bypass the lymphatic system, this results in decreased chyle flow, thus allowing the injury to heal faster. Delaney et al (2017)5 state that a MCFA diet alone does not stop chyle production.

If enteral tube feeding is indicated, a feed that is high in MCT would be the feed of choice. This feed would support in reducing chyle leak output as it would be absorbed via the portal vein and processed by the liver.

Some papers have suggested that all patients with chyle leakage should initially be started on a MCT/low-fat oral diet with total parenteral nutrition (TPN) then being considered if indicated. If the chyle output is persistent or high, then TPN is considered as it bypasses the lymphatic system, thus reducing/ not contributing to chyle production.11-13 Assessment is required to see if TPN is indicated given its associated cost, need for line access and risk of infection, etc.

Interestingly, Smith (2019)10 reports from her dietetic experience that a significant number of patients who are on TPN or enteral nutrition are kept nil by mouth (NBM) to reduce the amount of long-chain fatty acids being consumed.

However, she states that there is no justification for this and by doing so there is a risk of dehydration.

Clear fluids would not contribute to the chyle leak and thus could at least be considered for oral intake. Oral nutritional supplements that are classed as ‘clear’ could be considered also.

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SURGERY

Surgery is considered if other measures have been ineffective. References report that surgical re-exploration is considered when chyle output is >500-1000mls/day for five days.13-16 Sjoerd et al (2005)8 found that those individuals requiring reoperation had a chyle output of more than two litres per day and this continued for two days post conservative management commencing.

OTHER CONSERVATIVE MEASURES

Other conservative measures discussed by Delaney et al (2017)5 include bed rest, as chyle leakage is increased with physical activity, ensuring bowels are opening regularly and using a stool softener to reduce intrathoracic and intraabdominal pressure with bowel movement.

OUTCOMES

Developing a chyle leak increases patient morbidity and prolongs length of hospital stay. Sjoerd et al (2005)8 found that out of a sample of 536 patients who underwent oesophagectomy for malignant disease of the oesophagus, or gastro-oesophageal junction, 20 patients (3.7%) developed chyle leakage post-operatively. These patients as a result had significantly more pulmonary complications, longer intensive care unit stay, and thus a longer hospital stay.

Wakefield (2013)1 states that if ‘left untreated, the chyle leak would cause complications such as compression of surrounding tissues, impaired immunity due to the high content of lymphocytes present within chyle, and nutritional deficiencies due to the loss of calories, protein and fat soluble vitamins.’

For the patient I was seeing, enteral feeding with a high MCT feed was not successful alone to reduce chyle leakage and, due to the drainage of chyle remaining high, TPN was commenced. As the chyle leak resolved and the patient improved, an oral diet low in fat was commenced. The patient was fearful of foods that would contribute to chyle production.

On conducting an internet search, there seems to be very little patient information in regards to a low-fat diet for chyle leaks and perhaps emphasis on what foods can be eaten would be beneficial.

CONDITIONS & DISORDERS

MALABSORPTION Malabsorption is the clinical term to describe any defects occurring during the digestion of food and the absorption of nutrients.

Depending on the cause, the digestion or absorption of single or multiple nutrients can be affected.

Disruption of the normal digestive process can lead to malabsorption.

The aetiology of the malabsorption will determine the type and severity of the symptoms and deficiencies observed, also, whether the situation is acute or likely to become chronic.

There is a wide range of symptoms related to malabsorption, with abdominal discomfort, bloating, flatulence, diarrhoea and weight loss being commonly reported by patients.

Nutritional intervention is often required to manage malabsorption, including the use of exclusion diets, nutritional support and use of specialist nutritional products and/or supplements. In some cases, pharmaceutical intervention is also required. The intervention will depend on the definitive cause of the malabsorption.

THE STAGES OF DIGESTION

Our bodies require a consistent supply of nutrients to function and maintain themselves. Nutrients are used in many complex pathways in order to produce energy, enzymes, hormones, proteins, cells, tissues and bone and to fight infections. The diet we eat supplies the essential nutrients to complete these vital tasks.

The food we eat is digested in three stages. Table 1 overleaf shows each stage and gives examples of some of the conditions associated with those stages.

It is important to understand the mechanism of malabsorption in order to realise the impact it may have on the health of the patient. There are various stages of malabsorption depending on which point it occurs in the normal

process of digestion and absorption within the gastrointestinal tract.

FAT DIGESTION

During the luminal stage, long chain triglycerides are split into fatty acids and monoglycerides by lipase and colipase (pancreatic enzymes). They are then combined with bile acids and phospholipids, which form micelles.

The micelles are transported through the jejunal enterocytes to be reconstituted to make chylomicrons when combined with protein, phospholipids and cholesterol.

Chylomicrons are transported via the lymphatic system to ensure fats are utilised or stored. Medium-chain triglycerides (MCTs) are absorbed directly by passively diffusing from the GI tract to the portal system. MCTs do not require any modification for absorption, unlike longer-chain fatty acids. There is also no requirement for bile salts in order to digest MCTs. Patients experiencing malabsorption, or particular fatty-acid metabolism disorders, can be treated with MCT as part of their diet or feeds due to the relative ease of MCT digestion by the body.

Steatorrhea, defined as excess fat in the stools, is a clear symptom in fat malabsorption. Patients experience pale, bulky and offensive stools, which are difficult to flush away. It is commonly observed in pancreatic insufficient cystic fibrosis patients when Pancreatic Enzyme Replacement Therapy (PERT) is not effectively managed or taken by the patient. Patients with Crohnâ&#x20AC;&#x2122;s disease, pancreatitis disease, short bowel syndrome and liver disease are highly likely to experience steatorrhea.

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

FURTHER READING Visit: www.

NHDmag.com/ malabsorption

www.NHDmag.com November 2019 - Issue 149

31

CONDITIONS & DISORDERS Table 1: Stages of digestion and conditions causing malabsorption

Examples of conditions

Luminal

Mucosal

Postabsorptive

Stomach acids, pancreatic enzymes and bile from the liver break down proteins, fats, and carbohydrates. At this stage micronutrients are released from the food.

At the brush border within the small intestinal epithelial cells, the nutrients are absorbed from the intestinal lumen.

Once absorbed, the nutrients are transported throughout the body via the circulatory and lymphatic systems to be utilised or stored.

Biliary atresia; Cholestasis; Cystic fibrosis; Lactose intolerance; Cancers including pancreatic cancer, lymphoma or stomach cancer; Pancreatic insufficiency or diseases; Zollinger-Ellison syndrome; Medications that inhibit stomach acid production, such as phenytoin.

Coeliac disease; Inflammatory bowel disease; Radiation enteritis; Decreased intrinsic factor production; Surgery, such as a bowel resection or gastric bypass; Short bowel syndrome; Scleroderma; GI tract infections including viral, bacterial and parasitic infections; Whipple disease; Tropical spruce.

Liver diseases or cancer; Lymphangiectasia; Intrinsic factor deficiency, eg, pernicious anaemia; Blocked lacteals due to lymphoma or TB.

When fats are unabsorbed, fat-soluble vitamins (A, D, E, K) and possibly some minerals will be trapped within the fatty molecules. This leads to deficiencies, which can be managed by supplementation of the affected nutrients and the use of enzyme replacement therapy, such as lipase replacement in cystic fibrosis and pancreatitis patients.

The absorption of fats can be affected by bacterial overgrowth due to the deconjugation and dehydroxylation of bile salts. This has a limiting effect on fat absorption. Diarrhoea occurs due to the unabsorbed bile salts, which stimulate water secretion in the large intestine.

CARBOHYDRATE DIGESTION

Digestion of carbohydrates and disaccharides begins with the pancreatic enzyme, amylase and later the brush border enzymes, maltase, isomaltase, sucrase and lactase which continue to work on breaking down the complex sugars to create monosaccharides. Most of the newly created monosaccharides are absorbed in the upper small intestine. Unabsorbed carbohydrates are fermented by colonic bacteria to create a variety of waste products, such as carbon dioxide, methane, hydrogen and shortchain fatty acids including butyrate, propionate, acetate and lactate. The gases can be absorbed or 32

www.NHDmag.com November 2019 - Issue 149

excreted via breathing or flatulence. However, when malabsorption of carbohydrates occurs, excessive production of gas can cause abdominal distention, discomfort and bloating. Diarrhoea presents when there is an excess of the shortchain fatty acids.

Lactose intolerance (the appearance of clinical gastrointestinal symptoms after ingestion of lactose) is a common cause of the symptoms described above, with varying degrees of severity and longevity within the condition itself. The various types of lactase deficiency include congenital, primary and secondary lactase deficiency. Primary lactose deficiency occurs as lactase production decreases when the diet becomes less reliant on milk and dairy products. Usually, it presents after the age of two, but symptoms can take years to present, even into adulthood.

Secondary lactase deficiency occurs as a result of a condition or surgery affecting the small intestine. For example, secondary lactose intolerance can occur in the short term after a gastrointestinal infection. A temporary exclusion of lactose from the diet will be required with gradual reintroduction once symptoms are settled and the underlying condition is resolved or stabilised.

Congenital lactose intolerance is a rare genetic disorder where little or no lactase is produced. A

CONDITIONS & DISORDERS Table 2: Micronutrients and malabsorption Anaemias

Iron deficiency anaemia – often a manifestation of coeliac disease.

Microcytic (iron deficiency) or macrocytic (vitamin B12 deficiency).

Crohn’s disease or ileal resection – can cause megaloblastic anaemia due to vitamin B12 deficiency.

Clotting disorders

Vitamin K malabsorption and subsequent hypoprothrombinemia – can lead to complications in blood clotting.

Bone complications

Vitamin D deficiency – may lead to osteopenia or osteomalacia. Easy fracture of bones and bone pain.

Secondary hyperparathyroidism – can be caused by the malabsorption of calcium.

Neurological presentations

Malabsorption of vitamins B5 (pantothenic acid) and D – can cause generalised motor weakness Peripheral neuropathy due to B1 (thiamine), B6 (pyridoxine) and B12 (cobalamin) malabsorption.

Other complications can include night blindness (vitamin A), seizures (biotin). Loss of sensations such as vibration and position may be due to B12 (cobalamin) deficiency.

B12 deficiency also causes breathlessness and fatigue.

Hypocalcemia and hypomagnesemia, due to electrolyte malabsorption – can lead to tetany.

complete lifelong exclusion of lactose-containing foods and drinks is required in this instance. In primary and secondary lactase deficiency, there may be varying tolerance to lactose, therefore, individual assessment will reveal the level of restriction required.

Malabsorption affects both macro- and micronutrients. Deficiencies of micronutrients can present as a collection or more selectively. Table 2 shows some of the effects caused by micronutrient deficiencies associated with malabsorption.

PROTEIN DIGESTION

DIAGNOSIS, MANAGEMENT AND TREATMENT

Protein digestion is initiated by gastric pepsin within the stomach. It also stimulates release of cholecystokinin, which is vital for the secretion of pancreatic enzymes. A brush border enzyme, enterokinase, triggers trypsinogen, the precursor to trypsin. This pathway converts many pancreatic proteases into their active forms. Activated pancreatic enzymes act to hydrolyse proteins into oligopeptides. These are then absorbed directly, or hydrolysed into amino acids.

When protein is malabsorbed, symptoms such as diarrhoea, abdominal discomfort and bloating may occur. Oedema and ascites are symptoms of severe protein malabsorption.

Peripheral oedema is caused by hypoalbuminemia when there has been chronic protein malabsorption, or from loss of protein into the intestinal lumen. Ascites can develop when there are severe protein losses. Protein losses can be caused by extensive obstruction of the lymphatic system, seen in intestinal lymphangiectasia.

As faecal nitrogen is difficult to measure, tests to confirm protein malabsorption are rarely performed.

MICRONUTRIENT DEFICIENCIES

There are numerous tests performed to diagnose malabsorption and its underlying causes including: • a detailed patient history; • blood tests to screen for consequences of malabsorption; • stool fat testing to confirm malabsorption (if unclear); • diagnosis via endoscopy, contrast x-rays, or other tests based on findings.

More specific diagnostic tests (eg, upper endoscopy, colonoscopy, barium x-rays) are indicated to diagnose several causes of malabsorption.

When treating a patient who is experiencing malabsorption there are two approaches to consider: 1 Treat the underlying disease, eg, coeliac disease.

2 Provide nutritional support to correct deficiencies, encourage adequate growth in children and prevent weight loss in adults.

For examples of underlying diseases and treatment in malabsorption and for further reading, visit: www.NHDmag.com/malabsorption. www.NHDmag.com November 2019 - Issue 149

33

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September 2019

COMMUNITY

MALNUTRITION IN THE COMMUNITY SETTING: A NEW APPROACH TO TRAINING STAFF Malnutrition is increasing at an alarming rate, yet it is still often unrecognised and often untreated. Dietitian’s play a vital role in screening and treating patients. But can more be done? This article looks at a new concept in nursing home training to increase staff engagement.

Current evidence suggests that in the UK at present, malnutrition is 93% in the community setting, 2-3% in patients’ own homes and 5% in care homes.1 Those numbers are no doubt steadily on the increase, with malnutrition, just like obesity, being part of the ‘public health crisis’.

We know that the cost of malnutrition in both primary and secondary care is a significant burden on the NHS. Current expenditure is reported to be around 19.6 billion per year and more than 15% of total taxpayers’ money is spent on malnutrition.4 Significant cost implications are focused in the over 65 years category and in the elderly, as these are the most vulnerable groups.5 WHAT CAN WE DO AS DIETITIANS?

Dietitians have a vital role as part of the multidisciplinary team to impart expert evidence-based advice in primary, secondary and social care settings.

Dietitians also empower patients and

carers by providing adequate nutritional input and the screening needed, with the aim to reduce malnutrition effectively and to improve the overall dietetic treatment of patients. Effective communication, clear management plans, alongside education strategies, can help to reduce the effects seen in patients who show clear signs of malnutrition.

In a care-home setting, it can be difficult with dementia patients and those with other chronic conditions to maximise nutritional advice and, often, due to disease progression, it can be a challenging time for all involved in a patient’s care. Discussions with families and carers need to be had early on to explain the progression of the disease and the concept of rapid decline in oral intake of food and fluids.

Aiming to help the nursing home to take as much responsibility as possible, really does show positive outcomes and better nutritional care for patients. This could be through offering

Karen Voas Community Dietitian, Betsi Cadwaladr NHS Trust Karen is a Prescribing Support Dietitian with an interest in nutritional support and enteral feeding. Karen is also involved in the North Wales North west BDA Branch as Events Organiser.

REFERENCES Please visit: https://www. nhdmag.com/ references.html

Table 1: Symptoms and consequences of malnutrition Signs and symptoms of malnutrition

Clinical consequences of malnutrition

• Pressure sores/poor wound healing • Dry, fragile skin • Sunken eyes • Loose fitting dentures • Increase in chest infections/urine infections • Dry mouth • Unplanned weight loss • Muscle wastage • Poor appetite • Altered taste changes

• Increase risk of falls • Impaired recovery from illness and surgery • Increased morbidity and mortality • Impaired immune response • Frailty • Impaired wound healing • Reduced muscle strength

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COMMUNITY The 3D Model stays the same in any setting.

3D focuses on facilitating change and informing people correctly . . .

The Model can be used for any topic and works in both clinical and non-clinical settings, as the concept stays the same.

additional milky drinks, nourishing homemade milkshakes, which are nutritionally balanced and also high-calorie and protein snacks, which can promote better wound healing for patients who may be suffering with pressure sores but should be initiated by first line by the nursing home before dietetic input.

NICE 20175 indicates that we should be screening for malnutrition using a validated screening tool such as ‘MUST’. This should be done within 24 hours of admission to hospital, or in the community setting on a weekly basis, and carried out by an appropriate trained professional. The use of a training schedule can help in educating and empowering all nurses and carers involved in the care of patients at risk of malnutrition. Promotional weeks, such as Nutrition and Hydration Week and Dietitians Week can not only raise the profile of the profession, but also initiate and raise awareness of malnutrition in the community setting.

NURSING HOME TRAINING: A ‘3D’ APPROACH

The biggest challenge yet in dietetics I feel is training the wider staff members to implement an effective nutritional care plan. As part of my staff-engagement ambassador role, I aim to increase levels of engagement within staff and patient groups, to ensure that patients are getting the best care. Evidence suggests that

more engaged staff provide better healthcare outcomes for patients and for the overall organisation.6 There are many factors that contribute to employee engagement, including: • mutual respect in the workplace; • feeling of being trusted in what is done; • feeling of being listened to and of being involved; • feeling of empowerment to make effective changes within the workplace; • decision making; • ownership on change.

THE 3D MODEL – BACKGROUND

The concept of the 3D Model is mainly focused on staff engagement sessions, involving all staff (including nursing staff and healthcare professionals) to come together for a facilitated discussion and structured debate. The aim is to encourage more of a sense of ownership, innovation and productivity, ultimately leading to service development, or sometimes getting the views of others to facilitate change within their workplace.

Best practice is for the attendees to come up with their own action plans and to have the autonomy to take things forward and facilitate change, not necessarily with a manager’s say so. www.NHDmag.com November 2019 - Issue 149

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COMMUNITY Figure 1: The 3D Model – an overview6

Discover

Deliver

The Model can be used for any topic and works in both clinical and non-clinical settings, as the concept stays the same.

THE 3D STAGES

Discover The Discover stage is all about finding out where you currently are against a certain topic that has been identified by yourself as a team member, or engagement ambassador.7 This allows all staff to contribute by using post-it notes and jotting down all the ideas that come to mind during the session. This should be a positive stage where we aim to facilitate answers to change.

Debate The Debate stage is about taking a first step towards your preferred future, enabling staff to consider the issues mainly identified in the Discover stage.

The post-it notes are themed up and prioritised in order of personal importance. In this stage, it is vital to explain that this needs to be within their control: everyone can make change happen!

Deliver The Deliver stage is about reaching an end goal and getting things done, aiming to empower the attendees. Clear and timed action plans and delivery timescales are identified to move any actions forward. Other issues not in the group control need to be reported and fed back to other stakeholders involved.

REFLECTION

I have done several ‘3D events’, including one on ‘Nutrition and Food First techniques’, 38

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Debate

implementing it into the care home setting. At the time, the residential home was in special measures and they needed to show improvements. I decided to facilitate a 3D event so that they could start to take ownership of their residents’ nutrition and hydration and ensure that there was a nutritional champion at the end of it.

Initially, organising a specific date with the residential home, in order to allow me to run the event, proved problematic. This resistance from the start didn’t fill me with much hope for change! Nevertheless, the outcomes were extremely positive. During the event, it appeared that a lot of the carers seemed to have a ’poorer’ education level than the nurses, which I didn’t expect, so I had to quickly adapt the education session to suit them. They soon took on board the advice given and the result was better outcomes for the residents in terms of a reduction in hospital admissions, increase in weight and better hydration levels, with a knock-on in terms of less antibiotic prescriptions. I am hoping to plan the next event soon on a larger scale within my health board.

CONCLUSION

I think that having an ongoing relationship with care homes and being able to use and implement a valuable new way of working, has proved to encourage better outcomes with residents. The 3D Model aims to get people involved as much as possible and for the organisations to take responsibility for the care provided to patients.

Consider using the same method in your dietetic practice. it really can have a positive impact on malnutrition.

CONDITIONS & DISORDERS

NUTRITION IN MENTAL HEALTH RECOVERY When the NHS was founded in 1948, physical health and mental health were largely disconnected, but professional practice and attitudes have now improved significantly with the vast expansion of clinical evidence and advocacy. This article explains how nutrition plays a role in managing symptoms of various mental health conditions, with a special focus on depression.

Every year across the UK, at least one in four adults1-4 experiences mental health problems, with as many as one in six experiencing common mental health problems such as depression, general anxiety disorder, social anxiety disorder, panic disorder, obsessive compulsive disorder and post-traumatic stress disorder.5 Other mental health problems include, but are not limited to, eating disorders, bipolar disorder, psychosis and schizophrenia.6 Symptoms of depression,7 can vary from person to person, but generally speaking, an individual may experience low mood, feelings of guilt or low self-worth and loss of interest in things previously enjoyed, amongst many other symptoms. These persist for at least two weeks and may continue for months or even years, with some experiencing impact on their daily activities.

Victoria Chong Graduate BSc (Hons) Applied Nutrition from Glasgow Caledonian University.

THE ROLE OF NUTRITION IN MENTAL HEALTH

A biopsychosocial approach to mental health recovery is reflected in the clinical guidelines for managing anxiety,8 depression,9 bipolar disorder11 and schizophrenia.10 Healthcare professionals may recommend9,11 referral to a Registered Dietitian for dietary management of a physical health condition, particularly if this is chronic, as coping with chronic conditions can take a toll on oneâ&#x20AC;&#x2122;s mental health.9-11 Whilst nutrition does not cure mental ill health, it can be a key pillar13 in the self-management of symptoms, as well as in the prevention and management of physical health problems in those with mental health conditions, who often face significantly higher risk of developing poor physical health.17

Victoria has a wide range of interests in clinical dietetics and public health nutrition. Her special interests lie in renal nutrition and mental health.

REFERENCES Please visit: https://www. nhdmag.com/ references.html

Table 1: Basing meals around starchy options Aim for 8 to 10 portions a day32,34

One portion for an adult is equivalent to:

Breakfast cereal

3 tablespoons

Porridge oats

3 tablespoons

Bread

1 medium slice

Pasta (boiled)

2-3 tablespoons

Rice (boiled)

2-3 tablespoons

New potatoes (boiled)

2 egg-sized potatoes

Baked potatoes

1 medium size, with skin on www.NHDmag.com November 2019 - Issue 149

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CONDITIONS & DISORDERS Table 2: Portion sizes for plant and animal proteins Aim for two to three servings21,34 a day, of any source of protein

One portion of a good animal source of tryptophan, vitamin B12 and iron is roughly:

Cooked meats, such as beef/mince/pork/lamb/chicken/turkey/liver

1 deck of cards (60-90g)

Cooked white fish, such as cod/plaice/tinned fish

1 palm of hand (140g)

Eggs (yolk included)

2 eggs (yolk included)

Milk

1/3 pint (~200ml)

Cheese

1 matchbox size

Yoghurt/custard

1 standard pot (~150g) One portion of a good plant source of tryptophan and iron is roughly:

Beans, such as baked beans/kidney beans/butter beans/black eyed beans Pulses, such as chickpeas/lentils

4 tablespoons (~150g)

Soya/tofu

4 tablespoons (~100g)

Nuts

1 handful of nuts (~30g)

Nut butters, such as peanut butter

1 tablespoon (~30g)

Some medications may be accompanied by side effects, which may influence an individual's dietary intake, including: • an increased appetite or loss of appetite • nausea • dry mouth • insomnia and fatigue • weight gain • metabolic disturbances such as alterations in glucose and lipid metabolism.18,20 MOOD-MANAGING MEALS

Having regular meals that include starchy foods or wholegrains, a lean protein source and vegetables of various colours, will contribute significantly towards a healthy balanced and nutrient-rich diet.21 Spacing meals out throughout the day and making sure to include breakfast may help with building a routine.

The Eatwell Guide can be a useful reference for planning meals and choosing snacks that support a healthy mind.21 Eating healthily helps reduce the risk of vitamin and mineral deficiencies associated with symptoms of fatigue and irritability, which are also commonly experienced during episodes of depression and hypomania in bipolar disorder.12,14,18,20 40

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START STARCHY

Starchy foods, such as wholemeal bread, potatoes, rice, pasta, cereals and couscous are good sources of carbohydrates and vitamins including thiamine (vitamin B1) and niacin (vitamin B3).

Choosing higher-fibre or wholegrain options provides a steady release of glucose, the body’s primary source of energy, into the bloodstream and prevents slumps in energy levels. Avoiding large portion sizes32 and greasy or cheesy meals may also help prevent this. See Table 1 for portions.

GO GREEN

In terms of managing symptoms of poor mental health, folate (vitamin B9) and iron may help mitigate lethargy and aid concentration. Both are found mostly in green leafy and cruciferous vegetables such as broccoli, spinach, cabbage, Brussels sprouts and kale. Steaming or microwaving vegetables may also reduce loss of folate during cooking, as it is a water-soluble vitamin. Folate can also be found in fortified breakfast cereals, as with many other wholegrain foods. In future, there may be additional dietary alternatives, depending on the outcome of the ongoing open consultation33 on mandatory fortification of flour with folic acid.

CONDITIONS & DISORDERS Table 3: Portion sizes for oily fish Aim for at least one portion a week21,34

One portion of good oily fish as a source of vitamin D and zinc is roughly:

Salmon, Herring (kipper/sardines), Trout

140g (cooked weight), or 1 palm of hand One portion of good shellfish as a source35 of zinc is roughly:

Oysters, Mussels, Squid, Crab

75g or 2½oz

Although fruit and vegetables generally are not rich sources of zinc, small quantities can still be found in some.

One portion of relatively good plant as a source of zinc is roughly:

Beans, especially baked beans, but also: kidney beans / black eyed beans Pulses, such as: chickpeas / lentils

4 tablespoons (~150g)

Seeds, such as: pumpkin / sunflower Nuts

1 handful (~30g)

Nut butters, such as: peanut / almond / pine / cashew

1 tablespoon (~30g)

Folate deficiencies may exacerbate or worsen lethargy from chronic health conditions, or from poor mental health, as they are involved with bodily processes that regulate the production of haemoglobin. This is a protein found within red blood cells that is needed for circulating oxygen around our body.

Having at least five portions (one portion = 80g, or the size of a fist) throughout the day from a variety of fruit and vegetables, supports adequate intakes of naturally occurring antioxidants and fibre. These support a healthy immune system function, as a recent review28,29 of evidence from high-quality clinical trials, while conflicting, seems to suggest a potential for improvements of depression and anxiety symptoms.

PARTNER WITH PROTEIN

Tryptophan is an amino acid, a building block of protein, and is also a precursor of a neurotransmitter serotonin that plays a critical role in regulating mood. Research25-27 suggests that adequate consumption of foods from the protein food group may help with depression and anxiety.

Red meat, poultry, eggs and fish are good sources of vitamin B12 and iron, which help reduce the risk of anaemia-related tiredness.

Pairing citrus fruits or foods rich in vitamin C, and avoiding tea with meals, helps boost iron absorption.

OPT FOR OMEGA-3

Studies12,16 have shown that mood symptoms in depression and bipolar disorder may be mitigated with the inclusion of foods rich in long-chain omega-3 fatty acids, especially eicosapentaenoic acid (EPA) rather than docosahexaenoic acid (DHA).38 However, current evidence remains inconclusive and warrants further research.39 These fatty acids are mostly found in oily fish and shellfish such as oysters and some fortified eggs and milk, albeit in smaller quantities. Oily fish is also a good source of vitamin D and zinc, which, research22-24 suggests, may help with improving clinically significant mood states of anger and depression.

Although getting an adequate dietary supply of nutrients may help manage fatigue, feeling low and irritability, not all positive effects from regular consumption of specific foods are due to their nutrient content.25 HYDRATION HELPS, BUT CAREFUL WITH CAFFEINE AND ALCOHOL

Staying hydrated may help with managing low or irritable moods. Evidence shows that even a little dehydration can affect mood. The aim is for six to eight glasses (1.5 to 2 litres) of fluids every day. Water, tea, coffee, juices, milk or milky drinks, soups and yoghurt all count as fluids. The easiest and best indicator of drinking enough is a personâ&#x20AC;&#x2122;s urine colour,36 clear or pale yellow urine would be a sign of adequate hydration. www.NHDmag.com November 2019 - Issue 149

41

CONDITIONS & DISORDERS

. . .practitioners and individuals with mental health conditions may find a validated outcomes tool such as the Individual Recovery Outcomes Counter useful during their recovery.

Some drinks contain caffeine and some individuals may feel that this exacerbates or even triggers feelings of anxiousness and physical symptoms such as palpitations and nausea.

Limiting drinks containing caffeine may help prevent this. Caffeine-containing drinks include coffee, tea, Coca-Cola, products containing cocoa and energy drinks. Alternative caffeine-free products often have ‘decaffeinated’ or ‘naturally caffeine-free’ written on the packaging.

Many people enjoy alcohol as part of unwinding from a difficult day. While the short-term positive impact on mood makes it a tempting option to turn to, alcohol has a dehydrating effect, as it indirectly stimulates kidneys to produce more urine. Current recommendations encourage limiting alcohol intake to two to three drinks on a maximum of five days each week.21 When having a drink, avoid bingeing and alternate with a glass of water to prevent dehydration.

The relaxed or mood-uplifting effect of alcohol is due to its depressant impact on the central nervous system. However, in the long run, alcohol may interfere with the neurotransmitter balances in our brain that are needed for good mental health.19 If one drinks heavily regularly, this effect of imbalance eventually exacerbates feelings of depression and anxiety and makes us more prone to aggressive behaviour.19 Excessive alcohol consumption can also lead to B vitamin deficiencies, as well as impaired memory and cognitive function. B vitamins are required by our bodies in small quantities to aid release of energy stored in glucose. B vitamin deficiencies may cause some individuals to be more prone to feeling depressed or anxious.25 42

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Figure 1: The Individual Recovery Outcomes Counter (I.ROC)

PREPARING FOR DIFFICULT DAYS

For those living with mental health difficulties, healthy eating may mean developing practical strategies to work around symptoms that may pose as challenging barriers to maintaining healthy eating habits.30 SMART (Specific, Measurable, Achievable, Realistic, Timeframe-based) goal setting may help make healthy eating a regular occurrence by problem solving. For example, having ready-prepared meals in the freezer would help prevent the missing of meals and regulate portion control.

To achieve this, a person experiencing low motivation or anxiety about leaving the house, may arrange for grocery delivery, or request assistance from friends, family, or support workers, to buy ingredients. Making the most of better days to plan and prepare nutritious meals in advance can make a difference, especially at times when limits of one’s coping skills are tested.

Some mental health practitioners and individuals with mental health conditions may find a validated outcomes tool such as the Individual Recovery Outcomes Counter30,31 useful during their recovery (see Figure 1).

But, at the end of the day, there are many ways in which nutrition can support mental health recovery, in conjunction with other psychosocial and pharmacological treatments.

KETOGENIC DIET IN AN ADULT INPATIENT SETTING: A CASE REPORT

This case report aims to describe the lessons learned from trialling a ketogenic diet in a complex adult inpatient with super refractory status epilepticus (SRSE), referred to as ‘patient A’ in the interest of confidentiality.

The ketogenic diet is a high fat, low carbohydrate and adequateprotein diet recognised as an effective treatment for drug-resistant epilepsy in children.1 It mimics the starvation mode, thus inducing the production of ketones.

Despite its established success in this area, the evidence base for the use of a ketogenic diet in the treatment of adults with SRSE is more limited.

SRSE is where status epilepticus (SE)

continues for 24 hours or more after the initiation of anaesthetic therapy and includes cases that recur upon the weaning of anaesthetic agents.

Several case reports and cohort studies have provided preliminary evidence for the feasibility, safety and effectiveness of treating SRSE with a ketogenic diet in adults.2-4 However, further randomised, placebo-controlled trials are warranted to fully establish its efficacy.

CASE REPORT

NUTRITION MANAGEMENT

Emma Jones RD Royal Stoke University Hospital

Emma has an interest in major trauma and specialised rehabilitation.

Her current Band 6 role covers trauma, orthopaedic and neurosurgical wards, including the hyper-acute specialised rehabilitation unit within the Royal Stoke major trauma centre.

Patient A was admitted to the Royal Stoke University Hospital following a road traffic accident, in which she sustained a traumatic subarachnoid haemorrhage, acute subdural haematoma and multiple fractures. She remained nil by mouth and following a period of nasogastric (NG) feeding, a percutaneous endoscopic gastrostomy (PEG) was inserted to meet her full nutritional needs. Enteral feeding was tolerated well and her weight had been stable at approximately 60kg (BMI 23kg/m2) via a regime of 1260ml of Jevity Plus daily.

Five months post-admission and whilst on an acute rehab ward, patient A went into SE; her seizures became refractory to medical treatment and she required reintubation. EEGs confirmed ongoing partial status and, after multiple unsuccessful attempts at extubation, a tracheostomy was reinserted. Patient A was subsequently transferred from Critical Care for specialised rehabilitation, where she remained clinically stable, although in partial status.

REFERENCES Please visit: https://www. nhdmag.com/ references.html

Having exhausted anaesthetic and anti-epileptic drug therapies, her husband raised the possibility of a ketogenic diet as potential treatment option. Following multiple multidisciplinary team (MDT) discussions, the decision was made to commence a ketogenic diet trial, with the aim of resolving her SRSE. MDT WORKING The implementation of the ketogenic diet required extensive MDT working from the onset.

Having no personal experience of ketogenic diets in practice, or guidelines within our NHS Trust, I initially made contact with a specialist paediatric dietetic team who provided invaluable information regarding blood monitoring and treatment protocols. This included the bloods to be checked prior to commencing the diet, target ketone range and frequency of monitoring, as well as the treatment of potential complications such as hyperketosis and hypoglycaemia. Blood glucose and ketone levels were monitored every four hours, with the aim of achieving and maintaining a therapeutic level of ketosis – 2-5mmol/l – as advised by the specialist dietetic team. A treatment protocol was devised in case of hyperketosis or hypoglycaemia, whereby the carbohydrate supplement Polycal would be administered.

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NUTRITION MANAGEMENT Medications can provide a significant source of carbohydrate, and thus regular liaison with medicines information and the ward pharmacist was required in order to keep this to a minimum. Information from Matthew’s Friends5 (UK registered charity specialising exclusively in medical ketogenic diet therapies) and the Great Ormand Street website6 were particularly useful with regards to this. On occasion, the manufacturers of certain drugs were also contacted directly. Where appropriate, carbohydrate content was reduced by changing liquid formulations – often high in sorbitol – to crushed tablets.

The ketogenic feed was devised using individual components for protein and fat – Renapro powder and Calogen neutral respectively – with appropriate vitamin and mineral supplementation. As these are non-stock items in our Trust, this required regular liaison with both supplies and pharmacy.

The administration of a modular feed, as well as ketogenic blood monitoring, was also new to the nursing staff on the ward. To ensure safe and consistent delivery, I spoke with nursing staff daily throughout the treatment period, as well as ensuring that all senior staff were kept up to date. Besides nursing staff, close liaison with the medical team was key to the safe implementation of the diet; this included regular updates regarding progress, agreeing goals and outcome measures and advising on vitamin and mineral supplementation.

FEED TOLERANCE AND ADMINISTRATION A bolus regime was initially devised, consisting of both regular small boluses of Calogen neutral and dissolved Renapro powder (see Table 1). This was, however, poorly tolerated and ceased after day 3 due to recurrent vomiting.

Following discussion with the MDT, it was agreed to recommence the diet trial with two new strategies: a gradual introduction of the ketogenic diet using a step-wise approach (weaning the standard feed whilst gradually increasing the fat content); and using a flexitainer and pump for a slower delivery (see Table 2). The introductory process lasted for six days and no further vomiting occurred.

Although the continuous feed was well tolerated, technical issues were experienced with regards to pump delivery. Namely, the feeding pump regularly alarmed to say ‘feed empty’ shortly after commencing. Following discussion with our Abbott Nurse, this was felt to be caused by air in the mixed feed and was resolved by leaving the feed to ‘settle’ for approximately one hour prior to administration.

Table 1: Initial bolus regime Time

Feed

6am

50ml Calogen neutral; 1 x Renapro sachet

10am

50ml Calogen neutral

Noon

50ml Calogen neutral; 1 x Renapro sachet

3pm

50ml Calogen neutral

6pm

50ml Calogen neutral

9pm

50ml Calogen neutral; 1 x Renapro sachet

Table 2: Example of continuous regime Time

Feed

6am10am

Flexitainer: 150ml Calogen neutral 1 x Renapro sachet (1 x 20g) mixed in 150ml water (use shaker to mix) Run at 75ml/hour x 4 hours

5pm9pm

Flexitainer: 150ml Calogen neutral 1 x Renapro sachet (1 x 20g) mixed in 150ml water (use shaker to mix) Run at 75ml/hour x 4 hours

MEETING NUTRITIONAL REQUIREMENTS The use of a modular feed required careful consideration of vitamin and mineral supplementation. Whilst Forceval soluble met the RNI for most vitamins and minerals, it fell significantly short of calcium, potassium, magnesium and phosphorus. Liaison with the medical team enabled appropriate prophylactic supplementation to be prescribed and bloods were regularly monitored (see Table 3).

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NUTRITION MANAGEMENT Table 3: Prophylactic mineral supplementation Mineral

LRNI

RNI

Requirement/ kg (enteral)

Provision

Calcium

10mmol

17.5mmol

N/A

Forceval: 3mmol AdCal: 15mg

Potassium

50mmol

90mmol

1.0mmol/kg (=60mmol)

Forceval: 7.7mmol Renapro: 1.8mmol Sando K: 48 mmol

N/A

Forceval: 2.3mmol Renapro: 0.3mmol Magnesium aspartate: 10mmol

N/A

Forceval: 105mg Renapro: 44mg Phosphate Sandoz: 500mg

Magnesium

6.2mmol

Phosphorus

N/A

10.9mmol

550mg

OPTIMISING KETONE PRODUCTION Maintaining optimal blood ketone levels proved challenging, resulting in further liaison with the specialist dietetic team and several alterations to the treatment plan. Ketone levels were rarely within the desired therapeutic range (2-5mmol/l), with a ketogenic ratio of just over 2:1, and all options for reducing the carbohydrate content of medications had been exhausted.

To achieve a higher ketogenic ratio and upon advice from the specialist dietetic team, protein intake was temporarily reduced to 36g per day (equivalent to approximately 0.6g/kg of body weight). Optimal ketone levels were largely achieved, but began to reduce approximately three weeks into the diet and no cause could be identified. We had exhausted minimising the carbohydrate content of medications and, thus, the decision was made to trial adding medium-chain triglycerides (MCT) in the form of Liquigen. MCT yields higher levels of ketones per kilocalorie than long-chain triglycerides (LCT) and is, therefore, commonly used in ketogenic diet therapy. Unfortunately, this did not have the desired effect of optimising ketone production and optimal ketone levels became very hard to maintain.

OUTCOME Although some subtle changes were noted by the therapy team – for example, a higher WHIM (Wessex Head Injury Matrix) score – these were not consistent, and repeat EEGs confirmed that the patient remained in partial SE. It was therefore agreed with the MDT and patient’s family that there was no clinical indication to remain on the ketogenic diet trial. A standard feed was gradually reintroduced, and several months later the patient was discharged to a care facility.

CONCLUSION The safe implementation of a ketogenic diet requires extensive MDT working and robust treatment protocols.

As its use in adults with SRSE is very sparse, the adaption of paediatric guidelines proved necessary and invaluable. Although the ketogenic diet proved unsuccessful at resolving seizure activity in this case, there are multiple case reports which have shown its efficacy and, thus, further research is warranted.

t m en o m .c le ag pp m su HD ra .N Ext w D ww H N e at lin on

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The Magazine for Dietitians, Nutritionists and Healthcare Professionals November 2017: Issue 129

KETOGENIC DIET THERAPY

ONS AND DEMENTIA PREMATURE INFANT FEEDING ‘TEATOXING’ IBS & LOW FODMAPS

Coeliac disease & the GF diet pages 25-28

NHD Digital Don’t miss out on our digital-only issues of NHD. They are full of informative articles from our experts and essential information for all dietitians, nutritionists and healthcare professionals. View every issue online at

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F2F

FACE TO FACE Ursula meets: JAMIE BLACKSHAW Public Health England Team Leader for Obesity and Healthy Weight Registered Nutritionist 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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Competent cook and caterer

Jamie was waiting for me at the offices of Public Health England (PHE), which are near Waterloo Station in London. I was late; traffic etc. Jamie was reading the cover feature of the newest issue of New Scientist magazine, which pronounced that, ‘Everything you know about nutrition is wrong.’ My lateness and the crushing critique of our profession by New Scientist, was not the best start to our meeting.

But Jamie has the calm and courtesy of a diplomat. He began by telling me that he left school at 16 years old and Catering College offered a trade and a skill. To qualify for the BTEC National Diploma in Catering and Institutional Operations, he had to complete a maths qualification at night school and any spare time he had was filled by a parttime job in a restaurant. A short basic module on nutrition was the spark that lit the hob flames of his postkitchen career. “I was so lucky, in that my local polytechnic in Huddersfield offered a degree with both catering and nutrition,” he said. “I worked really hard, and even won a couple of awards.” It was a four-year course and during this time, Jamie enjoyed a 10-month placement with community dietitians in Leeds.

In 1995, Jamie graduated with a BSc (hons) in Food and Nutrition. He considered the option of a full-time post-grad Dietetics course, but chose instead a part-time Masters in Human Nutrition at the University of Sheffield, balanced with a job as kitchen manager

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Ursula meets amazing people who influence nutrition policies and practices in the UK. of a restaurant. “I went to Indonesia to collect data for my dissertation on rural versus urban breastfeeding practices, but then got caught up in the political unrest of May 1998. Unfortunately, I had to return to the UK and do my fieldwork in Sheffield and from data collected by colleagues in Indonesia,” explained Jamie.

His first job was scientific officer at the Ministry of Agriculture, Fisheries and Food (MAFF). He was in the dietary surveys team and worked on secretariat and technical support for M&W food composition, the NDNS surveys and the National Food Survey. Two years later, his job was the same, but administrative reorganisation meant a move to the newly formed Food Standards Agency (FSA).

Next, a transfer to a new team, ‘Nutrition Advice and Behaviour Change’ and, in 2005, a promotion to senior scientific officer. Jamie worked on the development of the FSA’s schoolsrelated work programme, which he described as “brilliant-amazingfantastic”. Educational resources were framed around the Food Competency framework, which supported schools as part of the then National Healthy Schools Programme. Jamie started listing the many projects he had led or supported: my pen scribbled, and “Yes, Chef” echoed in my ears. Other than healthy eating and curriculum resources for young people, Jamie contributed to many projects: the nutrition advice underpinning the School Food

F2F

He is currently the leader for the Obesity and Healthy Weight Team at PHE. The team support the government delivery of policy to tackle and prevent obesity,

Standards, the Change4Life campaigns, technical aspects for the Government Buying Standards for food, folic acid fortification discussions, a review of salt reduction, and Chief Medical Officer advice to healthcare professionals on preparation of infant formula. And much more.

No longer the breadcrust-dry civil servant, with careful and cautious comment, Jamie now showed the fizzing passion of a TV celebrity chef (the ‘other’ Jamie?). “I have always worked really, really hard, and I feel so lucky and proud to be a part of government decisions that support better public health in so many different ways.”

In 2010, Jamie moved to the Department of Health and during this time, he also completed a Masters in Health Policy at Imperial College London. His project was an investigation into the views of directors of Public Health on priority actions on obesity. He passed with distinction and his contribution was recognised when awarded the Nutrition Society Public Health Nutrition Medal in 2015. “It was the pinnacle of my career,” he smiled. “So humbling for my work to be recognised by the most senior UK policy makers and academics within nutrition science.”

Jamie has enjoyed several short secondments during his career, which have been great ways to learn new skills and meet other colleagues.

He worked in the transition team during the establishment of Public Health England (PHE).

And he especially enjoyed supporting the prepare-for-the-worst planners of the London

Olympics in 2012, as a member of the Emergency Preparedness team. Had his years of restaurant cheffing left him with some need for adrenalin boosts, I wondered? “Perhaps,” Jamie answered calmly.

He is currently the leader for the Obesity and Healthy Weight Team at PHE. The team support the government delivery of policy to tackle and prevent obesity, which spans ministerial briefings, supporting local authority programmes, and developing health service tools for NHS staff. The current themes are whole system approaches to obesity prevention to address the many complex interlinked promoters of societal weight gain. The team supports actions to be controlled and embellished locally, rather than just distributing general identical policies. And of course, PHE also contributes to the explosion of digital approaches, which help to support families with tailored and personalised diet and lifestyle options. Jamie collaborates with academia, third sector, local public health planners and healthcare professionals, and he is aware of many of the excellent community projects undertaken by dietitians.

We said goodbye in a mirrored lift. And I noticed that Jamie had two faces. The conscientious and considered civil servant and the confident combatant, fighting to make healthier choices easier. Perhaps he is the only nutritionist I have ever met who could also put on a chef hat, fire up the flames and literally ‘feed the four thousand’. www.NHDmag.com November 2019 - Issue 149

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A DAY IN THE LIFE OF . . .

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: https://www. nhdmag.com/ references.html

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A DIETITIAN ADVISOR TO NATIONAL SOCIETY FOR PHENYLKETONURIA Working for a small charity called the National Society for Phenylketonuria, I work with a group of people who have one of the most challenging and complex lifelong dietetic treatments I have come across as a dietitian.

This work is both fascinating and rewarding and I have the greatest respect for those who live with this metabolic disorder.

Phenylketonuria (PKU) is an inborn error of metabolism with an incidence in the UK of about 1 in 10,000. so we believe there may be about 6000 people living with PKU in the UK – although probably only about 3000 of them are diagnosed, with fewer than that attending specialist clinics. People with PKU are treated in the UK via a low phenylalanine (Phe) diet, with Phe prescribed in measured exchanges per day, in effect, a very low-protein diet and Phe-free protein substitutes.1 If an individual has PKU, or their child has, then the chances are, they spend a lot of time researching what to eat. When we, the NSPKU, undertook a survey (the biggest PKU patient survey in the world!), more than half of all respondents with PKU were taking less than 10 Phe exchanges daily – equivalent to 10g protein per day.2 This means that patients and families are reliant on lowprotein prescribable foods and they need to find manufactured foods that are lower in protein, such as new coconutbased cheese alternatives, some vegan products, ‘free-from’ manufactured foods, such as puddings, ice cream, baked goods and so on. European guidelines confirmed recently that this diet is for life.3 It is an incredibly complex diet.

Different foods have quite different protein contents and for every gram of protein content, the Phe content might vary too. For example, sweet potatoes are naturally low in Phe and are ‘exchange free’, but standard potatoes need to be weighed and counted at 80g per 1 x

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50mg Phe exchange for boiled or mashed potato and 55g for roast potatoes but only 45g for chips. Sweet potato fries and wedges are usually coated with either wheat or rice flour and so all food labels must be scrutinised and food weighed accordingly (although, if someone makes sweet potato wedges at home without a coating, then they are exchange free.) This is just one part of the diet. Planning how to get the right number of exchanges into a child to ensure that they have enough Phe to grow is important – if a child or adult doesn’t have the right amount of natural protein in a day, then there is risk of deficiency.

This constant, individualised diet research, planning, weighing and recording takes 19 hours/week4 when combined with the time it takes to negotiate the primary care prescription system and local or home delivery of dispensed items. (The PKU ‘community’ or patient population relies heavily on prescribable products.)

MY TYPICAL NSPKU DAY

8am-8.45am: Detailed dietary information via social media The @NSPKU Twitter account (me) tweets three to five foods per day as an information service to the PKU community – so it could be vegan cheese and what its exchange value is, comparisons between different rice or corn-based breakfast cereals and their respective exchange value, coconut ice cream and more. Accurate labelling is vital so that patients can weigh the amount of food that provides one gram

A DAY IN THE LIFE OF . . .

The Bath community members Step Forward for PKU.

Members of the NSPKU’s All-Party Parliamentary Group on PKU meet the Rt Hon Jeremy Hunt.

of protein (equivalent to one Phe exchange) and ensure they have the prescribed number of daily exchanges.

11am-1pm: Helping people with a rare disease overcome social isolation People who live with a long-term condition such as PKU assimilate that condition into their lives in different ways, and the NSPKU magazine aims to demonstrate that. Recording our events in the magazine is important too – the photo top left shows the community in Bath ‘Stepping Forward for PKU’, for International PKU Day (held on 28th June every year).

9am-10am: Dealing with prescription issues via NSPKU helpline I could be supporting someone who is struggling with their GP and not getting the prescriptions they need. Last week saw me (ironically, on ‘World Patient Safety day’), emailing a prescription administration team about a pregnant woman with PKU and delays in her scripts. In a registry of prescription issues undertaken earlier this year, we analysed 252 responses about poor access to prescribable products for PKU; in 47% of the responses the result of prescription delays or obstructions resulted in patients running out of prescribed food.5 Treatment disruption for very young children and pregnant women could have irreversible results on the brain development of the individual patient or their offspring. It’s my job to support patients by raising awareness of these risks.

10am-11am: Enabling low-protein school meals The NSPKU was set up in 1973 and the Medical Advisory Panel was established to inform our resources with a cross section of clinical expertise. We are currently writing a main dietary information booklet, but equally important is a project on resources to support children with PKU in receiving school meals, and a project to support eating out. If children cannot be like their friends and get a cooked meal, if they can’t be part of a family outing to a restaurant, then social isolation can occur, affecting quality of life. The dietitians volunteering their time for the NSPKU Medical Advisory Panel are developing written materials for use by school cooks, catering assistants and teachers, as well as for waitresses, chefs and restaurant managers.

2pm-4pm: PKU awareness work amongst NHS England and Public Health England, as well as the Dept of Health The NSPKU has set up an All-Party Parliamentary Group (APPG) on PKU to explore treatment access and to address the issue of the Soft Drinks Industry Levy and its adverse effects on the PKU community. Aspartame is a Phe ester, so any foods which have had aspartame added since the levy was introduced, are now completely off the menu for people with PKU. Also, the tax may be extended to other manufactured food groups, so raising awareness is vital. The photo (above) shows me explaining to the then Health Secretary the Rt Hon Jeremy Hunt, exactly how restrictive the PKU diet is.

4pm-5pm: Clinical dietetics: supporting Pregnant & Post Partum women with PKU Metabolic dietitians are working to develop practices that support the PKU community, including women after pregnancy. I send email newsletters to all NSPKU members, dietitians and dietetic assistants, providing them with news on new resources and products. People often send me information back which can then be shared. It is really rewarding to be part of such a committed and energetic community, which rises up to meet the challenges faced. www.NHDmag.com November 2019 - Issue 149

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EVENTS & PUBLIC HEALTH COURSES 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

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

THE ROYAL MARSDEN FOUNDATION TRUST 9th Mar 2020: Challenges of Non-Medical Prescribing in a Cancer Population 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

WORLD DIABETES DAY 14th Nov 2019 Berlin, Germany www.worlddiabetesday.org

INTRODUCTION TO PARENTAL NUTRITION 26th Nov 2019 - BDA Trainer - Carolyn Day London Road Community Hospital, Derby www.ncore.org.uk

OPTIMAL NUTRITIONAL CARE FOR ALL 19th-20th Nov 2019 Cambridge www.european-nutrition.org/homepage/ events/conference2019

BAPEN ANNUAL CONFERENCE - ICC BELFAST 26th-27th Nov 2019 25th Nov - Pre-conference teaching day www.bapen.org.uk/resources-and-education/ meetings/annual-conference

• Quarter page to full page • Premier & Universal placement listings • NHD website, NH-eNews and Network Health Digest placements To place an ad or discuss your requirements please call 50

www.NHDmag.com November 2019 - Issue 149

dieteticJOBS.co.uk

01342 824073

GOOD IMPRESSIONS… When I was a student dietitian, one of my trainers said to me that she was always nice towards her students as in the future they could end up being her boss! I always remembered that.

Dietetics is a small profession and you can always find a connection with someone else whether it be where you trained or connections through work.

My mum was a physiotherapist, so when I was thinking about a career, she encouraged me to looked at allied health professions. I thought about physiotherapy and occupational therapy, but decided that my love of food and caring for people meant that I was most suited to Dietetics.

Mum helped me organise my work experience at the busy Dietetic department at the Sheffield Children’s Hospital when I was 14 years old.

It was there that I met dietitians for the first time. The two dietitians I remember most were Sharon Lowry (as her husband was my Maths teacher) and Lesley Robertson.

The reason I remember them both is that they worked in the field of Inherited Metabolic Disorders (IMD), the speciality I work in now. In the last 10 years, I have met up with them regularly at conferences and meetings, often reminding them of when we first met during my work experience! Later, when I got married, I had to apologise to Lesley for being another ‘L Robertson’ working in the field of IMD! Attending conferences and meetings is an important way to meet our colleagues. I look forward to catching

up with other dietitians interested in the same areas as myself and discussing the latest research and practice. Not only do conferences enhance our learning, but we also make connections and can take the opportunity to network. This is very important, especially in rarer specialities.

Discussing with dietitians at other centres about their practice can be very valuable and improve our patient care.

Sharon retired a few years ago and Lesley retires at the end of this year. It feels like the end of an era for me. As a (slightly) younger dietitian, it is the feeling that I and my peers will now start to become the more senior dietitians in our field. Over the last years, Lesley and I have laughed together when people have muddled us up. I will miss her and the fun we have had, but I hope she enjoys her welldeserved retirement.

Those first impressions last. I am hoping I made a good impression while on work experience 25 years ago. One thing is for sure, Sharon and Lesley made a good impression on me and helped encourage me on my journey to become a dietitian. I aim to do the same.

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

www.NHDmag.com November 2019 - Issue 149

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GIVE ME STRENGTH Malnutrition can decrease muscle function.3 Loss of muscle mass is linked to an increased risk of falls and fractures,4 risk of infection, increased wound healing time, and an increased risk of mortality.5

Ensure Plus Advance is the only oral nutritional supplement in the UK that contains high levels of protein, with additional vitamin D and calcium β-hydroxy-β-methylbutyrate (CaHMB).

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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.

ANUKANI190221g Date of preparation: August 2019

1,2*†