Network Health Digest - Dec 19/Jan 20

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

Dec 2019 /Jan 2020: Issue 150

WEANING PRETERM BABIES

NASOGASTRIC TUBE FEEDING FUSSY EATING IN TODDLERS CONSTIPATION & TREATMENT POPULAR LIQUID DIETS FOLLOW-ON FORMULA: NEW REGULATIONS CARE CATERERS IN SOCIAL CARE F2F WITH GREG LESSONS

Plant-based diets: nutritional considerations Pages 19-21

THERE’S A PAEDIASURE TO SUIT EVERYONE ON BOARD w

PaediaSure is the most popular ONS* brand for children in the UK,1 and has a great taste that kids love.2-5 From standard to energy dense, with or without fibre, juice style or peptide-based, there’s a PaediaSure to suit every little monkey (elephant, or zebra).

*Oral Nutritional Supplement

REGISTER FOR A FREE DIRECT-TO-PATIENT SAMPLE AT

samples.nutrition.abbott Passcode: samples

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 Welcome to this final issue of 2019 and the first of 2020!

We’ve made it through another 12 months, and we welcome in not on only a new year but a new decade – the NEW roaring 20s!

It’s amazing to think that 100 years ago we were on the verge of a decade that saw a collection of truly life-changing discoveries, inventions and creations.

During the 1920s, the first commercial radio station was launched, soon to be followed by the advanced development of television towards the end of the decade by John Logie Baird. Music and television were only just starting to reach the masses, a huge step up at the time from reading the latest news in the broadsheets and still a world away from the 24/7 online access we have to information resources.

In health and nutrition, insulin was first used in the treatment of diabetes in 1922, discovered by Banting, Best and Macleod at the University of Toronto and we also saw new vitamins being identified and researched. In 1928, Adolph Windaus received the Nobel Prize in Chemistry, received for his studies on vitamin D and its connection with sunlight. Sir Frederick Hopkins and Christiaan Eijkman also received a Nobel Prize in 1929 for their work around ‘growth stimulating vitamins’, which we now know as some of the B vitamins.

We saw all women over the age of 21 being granted the vote in 1928. Women felt more confident and empowered, with new independence, which was reflected in the fashion and styles of the day. Hair and dresses were shorter; women started to smoke, drink and drive motorcars. The ‘flapper’, who was generally considered attractive, reckless

and independent, appeared on the scene; with her wild behaviour, she was often shocking to society. 1920s-style girl power was definitely a thing!

And it was not just the female Bright Young Things who were making changes in the 1920s. In early 1924, Margaret Bondfield, was appointed as Parliamentary Secretary to the Minister for Labour – the first woman ever to become a government minister.

The 1920s saw an almighty boom in many things creative, nutritional, industrial and societal; setting the wheels in motion for life as we know it today. However, poverty within the working classes was stark in contrast to the middle and upper classes.

The end of the decade saw mass unemployment, poverty and economic decline, leading to the depression of the 1930s.

We start the ‘new’ 20s in a challenging position, not fully sure of the political events that will unfold over the coming months, with concerns for our NHS and social care on the agenda. You could say that little that has changed in our society since those discoveries and innovations of the 1920s.

However, there is always scope for new ideas and new ways of working. The 2020s are sure to be a rollercoaster ride, but we’ll no doubt create our own version of the ‘roaring 20s’ with added modern twists! Emma

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

www.NHDmag.com December 2019 / January 2020 - Issue 150

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9 COVER STORY Weaning preterm babies 6

News

8

Infant and follow-on-formula

Latest industry and product updates

New regulations

37 Care caterers

Delivering person-centred mealtimes 44 F2F

15 FUSSY EATING IN TODDLERS

19 Plant-based diets

Nutritional considerations 23 Nasogastric tube feeding

An overview

Interview with Greg Lessons Nutritionist,

London Firebrigade

41 Organic food

Is it the healthier option?

47 A DAY IN THE LIFE OF . . .

27 CONSTIPATION & TREATMENT

50 Events, courses & dieteticJOBS

Dates for your diary and job listings

32 Liquid diets

A look at five popular examples

51 Dietitian's life

Back to the future

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

4

ISSN 2398-8754

Phone 01342 825349 Fax 0844 774 7514 Email info@networkhealthgroup.co.uk

@NHDmagazine

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 December 2019 / January 2020 - Issue 150

nhd_dietetics

THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS USE ONLY

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

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

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

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

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

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

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

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

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

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

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

Composition

Preterm breast milk

nutriprem 1

Gold Prem 128

nutriprem 2

Protein ratio

60:40 whey:casein3

60:40 whey:casein

100% whey

60:40 whey:casein

100% whey

Protein type

Over 99.9% intact protein4

100% intact protein

100% partially hydrolysed protein

100% intact protein

100% partially hydrolysed protein

Lactose

Lactose

Maltodextrin

Lactose

Lactose

7.3g/100ml26

5g/100ml

3.7g/100ml

5.9g/100ml

5.3g/100ml

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

7-17%

15–18

10%

39.5%

Gold Prem 228

10%

~6%

Up to 20% of LCPs12,14

15% of LCPs

0% of LCPs

15% of LCPs

0% of LCPs

Naturally occurring

Natural milk fat

Structured vegetable fat

Natural milk fat

Structured vegetable fat

0.5-1.1g per 100ml27

0.8g per 100ml

No prebiotic OS

0.8g per 100ml

No prebiotic OS

1.2mg/100ml

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

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

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

NOT nutritionally complete**

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

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

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

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

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

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

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

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

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

@NutriciaELNHCP

19-035. August 2019

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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product news for the next

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LIMITED DIETARY KNOWLEDGE RISKS POOR HEALTH IN VEGETARIANS A new survey recently commissioned by the Health and Food Supplements Information Service (HSIS),1 has highlighted worrying gaps in knowledge, leading to an enhanced risk of nutritional deficiencies. The OnePoll survey interviewed 1000 vegetarian and vegan adults across the UK and found that 28% of vegans and 13% of vegetarians have been diagnosed with a nutrient deficiency following a blood test.

The key nutrients which could be an issue on vegetarian or vegan diets were iron, vitamin D, vitamin B12, calcium and zinc. These are all found in animal-sourced foods, but tend to be less bioavailable, or present in smaller amounts, in plant foods. Yet, despite this, more than 6 in 10 people claimed that their plant-based diet provided all the nutrients they need.

The examples of deficiency were accompanied by poor general knowledge about how to obtain adequate nutrient intakes when following a vegan or vegetarian diet. Whilst 1 in 10 respondents had turned to a meat-free diet in the past year, and half had been vegan or vegetarian for longer, 60% overall admitted that they had done no research before cutting out animal products and most did not take a targeted dietary supplement, as recommended by the NHS and the Vegan Society.

The HSIS survey found that advice on diet and nutrition came mostly from family and friends (32%), wellness blogs and celebrities (25%), or newspaper and magazine articles (14%). Only a quarter were aware of iron and zinc issues and 6% were aware of iodine deficiency. Significant groups believed – wrongly – that apricots, spinach, mushrooms and apples are high in protein, or that broccoli (33%) and pulses (20%) were good sources of vitamin B12. One in four had no idea where to get omega-3s in the diet and 1 in 10 worried unnecessarily about lack of vitamin C, which is a negligible risk in a plant-based diet. Turn to page 19 for more on plant-based diets.

1 www.hsis.org/vegetarian-and-vegan-trends-pushing-more-people-into-deficiency-risk

SUGAR REDUCTION: REPORT ON PROGRESS 2015-2018 Public Health England (PHE)’s second-year report on progress made by the food industry to voluntarily reduce sugar in everyday foods, shows an overall 2.9% reduction since 2015. Retailer own-brand and manufacturer branded yoghurts and fromage frais, and breakfast cereals have reduced sugar by 10.3% and 8.5% respectively.

Progress has been made under the Soft Drinks Industry Levy (SDIL), including a 28.8% sugar reduction per 100ml in retailer own brand and manufacturer branded products and a 27.2% reduction per 100ml for drinks consumed out of home.

There has been a consumer shift towards zero or lower sugar products, with sugar purchased from soft drinks decreasing in all socio-economic groups. The amount of sugar removed – 30,133 tonnes – has been done so without reducing soft drink sales, resulting in around 37.5 billion fewer kilocalories sold in sugary drinks each year.

For the full report: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/839756/ Sugar_reduction_yr2_progress_report.pdf

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www.NHDmag.com December 2019 / January 2020 - Issue 150

NEWS THE ULTIMATE CHOLESTEROL LOWERING PLAN© UPDATED The facts and figures around heart health and cholesterol are stark. Coronary heart disease (CHD) remains one of the major killers in the UK: 2.3 million people are living with CHD and 64,000 die of CHD every year, with high cholesterol levels being one of the major risk factors to CHD. However, around 93% of these deaths have been attributed to risk factors that can be modified: dietary habits and lifestyle.

Heart UK’s Ultimate Cholesterol Lowering Plan© (UCLP©), originally developed in 2011, addresses diet, with the aim of reducing cholesterol and managing heart health. The step-by-step plan is based on both heart health science and behavioural strategies, with users encouraged to build the plan that suits them best, so that change is realistic and easy to maintain.

Download the updated UCLP© here: www.heartuk.org.uk/ultimate-cholesterol-lowering-plan/uclp-introduction. You can also access a free webinar to learn more about the latest evidence and updated plan here: www.nutrilicious.co.uk/the-uclp-webinar/

HELPING OLDER PEOPLE TO REMAIN HEALTHIER FOR LONGER A new report published by the British Geriatrics Society, Healthier for Longer: how healthcare professionals can support older people, examines how messages of prevention and healthy ageing apply to an older population group that may already be ill and frail, and to the HCPs who care for them.

The prevention agenda, which has been highlighted as a priority for the Government and for health services, is shown in this report to be as relevant to the older population as it is to younger age groups. While the gains of prevention in relation to older people’s health may be modest in terms of years of life gained, the impact in terms of quality of life is likely to be significant.

The report highlights steps that all HCPs can take to help promote healthy ageing and prevention in later life. These include: • ‘Care at every contact’ – every touchpoint of care is a potential opportunity to help people to engage in their own health and work with others to improve it.

• ‘Cover the basics’ – older people need to be able to see, hear, eat, drink and sleep well even if other more complex health issues are being addressed.

• ‘Consider the whole person’ – healthcare issues may not be the only or even the most pressing concern for a patient. Ask what matters to them and how they can be supported.

Download the report here: www.bgs.org.uk/sites/default/files/content/resources/files/2019-11-04/BGS%20Healthier%20for%20Longer.pdf

NEW PORTION SIZE GUIDE LAUNCHED FOR INDUSTRY The Institute of Grocery Distribution (IGD), a research and training charity, has published a new guide for food businesses to help them review and set portion sizes, in a bid to help consumers reduce their calorie intake. The guide has been developed following extensive consultation with industry and is based on qualitative consumer research on eating out, on the go and in the home.

More information on the guide is available to download at: www.igd.com/charitable-impact/healty-eating/reformulation/focus-areas/portion-size

www.NHDmag.com December 2019 / January 2020 - Issue 150

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PUBLIC HEALTH

INFANT AND FOLLOW-ON FORMULA: NEW REGULATIONS The regulations for infant formula (IF) and follow-on formula (FoF) are changing and will apply from February next year, which means that formulations are likely to change. HCPs should make themselves familiar with the new regulations so that they can help and support parents.

Naomi Brown Scientific and Regulatory Manager, British Specialist Nutrition Association Ltd (BSNA) Naomi has a First Class Honours degree in Nutritional Science and an MSc in Public Health Nutrition.

She has worked in the nutrition industry for several years. www.bsna.co.uk

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

Detailed regulations are in place for specialist food products including IF, FoF, food for special medical purposes (FSMPs) and complementary weaning foods. These regulations ensure the safety, quality and high nutritional standards, safeguarding the vulnerable consumers for which these products are intended.

Since 2016, IF and FoF have been regulated by the ‘Foods for Specific Groups’ (FSG) framework, specifying the nutritional composition, labelling and health claims. Under the FSG framework, the specific specialist Directive 2006/141/EC on IF and FoF has been updated and will be replaced

by Commission Delegated Regulation (EU) 2016/127. This will apply from 22nd February 2020 (except in respect of IF and FoF manufactured from protein hydrolysates to which it shall apply from 21st February 2021).

To ensure compliance by 22nd February next year, manufacturers are beginning to implement the required changes with some reformulated products already present in the market. Changes, based on the latest scientific research1 into IF and FoF, are mainly compositional. The addition of docosahexaenoic acid (DHA) is now a mandatory requirement and a range of 20-50mg/100kcal has now been set. DHA, along with arachidonic acid (ARA), is a long-chain fatty acid present

INFANT NUTRITION INDUSTRY CODE OF PRACTICE

in breastmilk that plays an essential role in early infant development, particularly in the neural tissues of the retina and brain.2 Both DHA and ARA are preferentially transferred to the foetus across the placenta3, their accumulation in the foetal brain mainly takes place during the third trimester and continues at very high rates up until two years of age. Intervention studies have shown the role of DHA supplementation in benefiting cognitive function, visual acuity and immune response.4 Other nutritional changes coming into force include an introduction of a maximum level for alpha-linolenic acid (ALA) and small increases in the minimum levels of copper, iodine, selenium, sodium, potassium, chloride, vitamin A and vitamin D. Some nutrients, such as vitamin B6, biotin, vitamin C and vitamin K, had lower minimum levels set. These changes may result in updated nutritional declarations on product labels. Small labelling changes will also occur, such as folic acid to be declared as folate, while the units for niacin and pantothenic acid have changed from μg to mg.

Parents may notice a slight difference in the smell, appearance or taste of the products due to these changes. Settling issues may also be noticed, but these should only be temporary and minimal.

The British Specialist Nutrition Association (BSNA) has launched a new Code of Practice for the manufacturers of formula milks in the UK. The Infant Nutrition Industry (INI) Code is designed to shed more light on how the UK infant nutrition industry operates and the high standards that can be expected. For more information on the Code, please visit: www.bsna.co.uk 8

www.NHDmag.com December 2019 / January 2020 - Issue 150

COVER STORY

WEANING PRETERM BABIES Around 10% of babies are born prematurely; this means that they have missed some or all of the third trimester of pregnancy when nutritional stores are laid down.

This article provides advice on weaning a preterm infant, including ready-for-weaning cues and steps for ensuring that it is a positive experience for all involved.

Nutritional care on the special care baby unit has improved over the last decade and many baby’s will have achieved catch-up nutritional status. Some, however, may still be at risk of malnutrition and poor growth and will require individualised weaning guidance.

There is a lack of government guidance on how and when parents should wean their preterm baby, which means that personalised weaning advice is often needed due to parental anxiety and uncertainty about whether their baby has adequate motor skills.

Sarah Almond Bushell MPhil, BSc, RD, MBDA

Preterm babies who have other medical needs, or who have had a complex neonatal period, may be at higher risk of nutrition and feeding problems linked to the developmental delay of eating and drinking skills.

CORRECTED AGE AND ACTUAL AGE

WHAT IS CONSIDERED PRETERM?

A preterm baby is one who is born before 37 weeks gestation. However, if they were born after 34 weeks, are growing well and are otherwise healthy, they may be able to follow general weaning guidance rather than the specialist information given here.1

Actual age is the baby’s age from the date they were born, whilst corrected age takes into account how preterm they were and is counted from their due date. For example, a baby born at 32 weeks who is 14 weeks old, would be six weeks corrected. The corrected age allows healthcare professionals to assess the baby’s development appropriately.

In this example, the expectation would be for the baby to be reaching the usual milestones of a six-week old rather than a 14-week old baby.

Both actual and corrected are used by healthcare professionals.

WHY ARE PRETERM BABIES MORE COMPLEX?

WHAT AGE SHOULD YOU START WEANING A PRETERM BABY?

Some babies may be smaller than expected, weighing less than 2.5kg at birth, referred to as low birth weight (LBW). Other babies may have Inter uterine growth retardation (IUGR) which can occur at any gestation. These babies will need their weaning diet carefully planned to achieve catch-up growth without altering body composition.

Sarah is a children’s nutritionist and baby weaning expert with 20 years’ experience in nutrition and dietetics. She is a trained SOS feeding therapist and is passionate about helping families improve their nutrition to optimise health. www.childrensnutrition.co.uk

@thechildrensnutritionist @feedingbabies

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

NHS guidelines advising that weaning should start at around six months of age don’t apply to most preterm babies.

There is very little research specifically for preterm babies and a recommended age is not suggested.2 The key is to understand the baby’s developmental milestones and to look out for their readiness cues. Consider the following www.NHDmag.com December 2019 / January 2020 - Issue 150

9

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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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COVER STORY three signs for being ‘ready for weaning’ for term babies3 and see how the preterm baby might differ: The tongue-thrust reflex One of the signs of being ready to wean a term baby is the absence of the tongue-thrust reflex. This is tongue protrusion in response to something touching it. In many preterm babies the tongue-thrust reflex is present and regular practise by eating food helps it abate.

In summary: you don’t need to wait for the absence of the tongue-thrust reflex when thinking about weaning a preterm baby.

Being able to sit unaided Many preterm babies will not have the motor skills to be able to sit up unaided. However, postural stability is essential for optimal oral-motor range of motion, hand-eye coordination and fine motor and tactile manipulation of food. This can be provided with appropriate seating in a well-supported highchair. Support is required at the feet, behind the knees and around the waist and trunk. This is necessary so that the baby can concentrate on coordinating the skills needed for eating rather than prioritising vestibular and proprioceptive senses.

In summary: Premature babies don’t need to be able to sit up unsupported to commence weaning, but supportive seating must be provided.

Good hand-eye coordination In babies born at term, hand-eye coordination is needed so that they can start self-feeding irrespective of whether they are baby-led weaning (BLW) or traditionally weaning (see below for more on these weaning methods), because finger foods are important from 6.5 months. Many preterm babies won’t have good hand-eye coordination at the start of weaning and will need to be spoon-fed.

In summary: Premature babies do not need to have hand-eye coordination before they can start weaning.

WHAT ARE THE READINESS CUES?

The following cues2 can be helpful to decide whether a baby is ready to start solids. Babies don’t need to have all the following in place and often parents are the best judge of when their

baby is ready. Individual assessment of each baby is important.

• Holding their head steady. When sitting upright in a supported position, preterm babies need to be able to hold their head steady in the midline for successful weaning. If babies also have other ongoing medical problems, their gross motor, fine motor and oral motor skills may be impacted. Therefore, waiting until a minimal level of motor ability is present (such as holding their head steady) is important prior to starting solids. Many babies achieve this at around four months corrected age.

• Picking up toys and putting them in their mouth to explore.

• Leaning forward, mouth open ‘asking’ for food.

• Showing an interest in the food that others are eating. Some feel that this could be a sign for being ready for weaning, but many babies do this anyway and so this should not be taken as a cue in isolation.

They are not ready: • when the baby appears hungry and is demanding more milk; • when the baby is waking more frequently though the night to feed; • when they reach a certain weight; • when they reach a certain age.

IS NUTRITION A REASON TO START SOLIDS?

Yes, it can be. Meeting energy requirements is a reason to consider starting solids. Beyond a certain point, breast milk alone can’t provide enough energy to meet a baby’s nutritional requirements and, so, starting solids is necessary to complement it and meet their energy needs.

Traditional first weaning foods, such as vegetables and fruit, are low in energy and don’t contribute much towards meeting energy requirements. At the same time, milk intake may decrease as it becomes displaced by food. Progression towards including meat, fish, dairy foods and starchy carbohydrates is important to provide the additional nutrients required.

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COVER STORY Table 1: Recommendations for vitamin supplements Vitamin A

200mcg

Vitamin C

20mg

Vitamin D

8.5 to 10mcg

Babies born at term have around six months’ supply of iron before it runs out and they need to obtain it from solid food. As iron is laid down in the third trimester of pregnancy, preterm babies often don’t have this luxury. Breastfed babies will be discharged from hospital on an iron supplement and formula-fed babies will receive supplemental iron via their formula. Iron supplements should continue until babies are consuming adequate iron in their weaning diet.

Iron from food sources is more readily absorbed than iron from supplements.

All babies, irrespective of their gestation, will need to progress through the stages of weaning and onto a balanced weaning diet in order to meet their nutritional requirements.

The rate of progress is driven by skill rather than hunger in the early months, and parents should be encouraged to observe and respond to their baby’s cues.

Vitamin A, C and D supplements are also recommended for all babies,4 and those having more than 500ml formula/day will receive these already, but breastfed babies will need supplementary drops. Not all supplements are equal, each containing different amounts of the three vitamins, so dietitians should consider the nutritional quality of the weaning diet when considering which supplement is best.

WHICH METHOD OF WEANING IS BEST FOR A PRETERM BABY?

There are two approaches to weaning: • Traditional weaning, which involves feeding the baby smooth purees from a spoon, gradually increasing the texture and providing finger foods alongside.

• Baby-led weaning (BLW), which involves providing food in its whole form and allowing the baby to explore the food and self-feed.

The decision on which method is best for a preterm baby must be based upon their development to ensure safety.

12

For many preterm babies, BLW may not be advisable as it requires them to have adequate stability in an upright seated position and proficient hand-eye coordination. Without a stable base, they are at increased risk of choking and without hand-eye coordination, they simply can’t bring the food up to their mouths.

Nevertheless, hand-eye coordination is a skill they need to learn through regular practice, so offering finger foods alongside purees can be helpful. Sometimes, parents refer to this as ‘a combined approach.’

It is known that BLW babies consume less nutrition at the start of weaning while their skills are being learned.5 Therefore, if growth is an issue and a carefully planned weaning diet is important, BLW may not be possible in order to achieve the required catch-up growth.

If babies have medical conditions or issues with swallowing as a result of being preterm, it’s likely that they will be under a feeding team or speech and language therapist who may have an individualised plan for weaning.6 HOW TO OFFER THE FIRST MEAL

The initial focus of starting solids is about enjoyment, not the volume of food. The aim is to establish positive feeding interactions between the parents and the child. Parents may need to be taught how to use a highly expressive happy face and how to manage their own facial expressions to hide their own feeding anxieties.

They must reassure their baby that eating solid food is a positive experience.7 Here are some steps for positive feeding interactions (this phase may last two to four weeks in some premature babies before they get used to taking food from a spoon).

1 Parents must begin with a highly expressive happy face to provide reassurance.

2 A small amount of puree should be placed directly on the highchair tray.

3 Show the baby the spoon and tell them what they are having to eat.

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COVER STORY 4 Take up a scant trace of the puree on the tip of the spoon.

5 Bring the spoon straight up to the baby’s mouth and leave a scant trace of puree on their bottom lip, then withdraw the spoon.

6 The parent should model lip smacking movements to encourage their baby to copy and take a taste of the puree.

7 The next step involves the scant trace of puree being placed inside the baby’s mouth on the inside of the lips.

8 Parent should say “aaaahh” as the spoon approaches to help encourage opening the mouth, and “mmmm” to encourage closing.

9 The next step involves placing the trace of puree on the tip of the tongue with parents using the “aaahhhs” and “mmmms” to encourage opening and closing.

Steps can be repeated with increasing volumes of puree while the baby is content. Let the baby touch and play with the puree and have their own spoon if they show interest.

It’s important that parents observe their baby’s cues and stop before the baby loses interest or becomes upset. Cleaning up, face wiping and spoon scraping are unpleasant for babies and should be avoided during the mealtime. It can be helpful if cleaning up happens away from the highchair to avoid negative associations with weaning.

CUP INTRODUCTION

Cup drinking is another skill to learn and the volumes of water taken at the start of weaning don’t contribute much to their fluid intake.

Introduction of the cup is for practice initially.

A free-flow, two-handled spouted beaker can be helpful to start with, as water flows too fast from open cups. The cup should be filled to half full, so it doesn’t need to be tipped too far for the water to flow. The parent should introduce the cup at the end of the meal and demonstrate how it works by tipping water onto the highchair tray first7 before offering it to their baby.

THE RISKS OF DELAYED WEANING

It is not uncommon for parents to want to delay the introduction of solids, as they feel that their

baby is not yet developmentally ready. Aside from the risk of poor nutritional status and growth, many babies benefit from the challenges that weaning brings and it may enhance the progression of their eating and drinking skills. There is little evidence to detail how much oral motor abilities are learned through practice. However, those babies who don’t have challenging solid foods at this time appear to be at greater risk of feeding difficulties.6 It is not uncommon for preterm babies to remain on pureed food for longer than necessary due to parental concern that they may not cope with lumpy textures and choke. Because challenging textures can be helpful to aid skill development, coupled with the developmental ‘window of opportunity’8,9,10 when babies are open to accepting new flavours and textures, it has been suggested that a delay beyond nine months uncorrected age for the introduction of lumpy textures could lead to feeding problems so must be avoided.

SENSORY WEANING

Exposure to food is not enough for it to be accepted in the long term.11 There are eight senses involved in weaning, which must be encouraged and explored as part of learning how to eat and drink.7 The eight senses are as follows: 1 Visual (sight) 2 Tactile (touch, textures) 3 Auditory (sound) 4 Olfactory (smell) 5 Gustatory (taste) 6 Proprioception (location/orientation of self in space, eg, movement) 7 Vestibular (balance and orientation of self in relation to gravity) 8 Interoception (the ability to read and interpret internal bodily signal, eg, feeling hunger) Studies have shown that babies who have lots of opportunities to use their senses have a more complex map of neural connections in the brain linked to food acceptance, developmental skills, intellect and behaviour12 The best way to encourage sensory weaning is to offer many opportunities for exploration, for example, messy play with a variety of

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COVER STORY different textured foodstuffs, presenting food in colourful combinations and offering a variety of different textures.

INTERACTION WITH PARENTS: RESPONSIVE FEEDING

Term babies around four to six months of age can communicate their needs to their parents and caregivers. 13 There is some evidence that preterm babies are able to do this too in relation to feeding. 6 A baby will turn their head away when they’ve had enough or lean forward with an open mouth when they want more. Parents should be encouraged to take notice and respond to these subtle cues and develop an appropriate food parenting style. 14 Responsive feeding ensures that: • the mealtime environment is calm and enjoyable with no distractions; • the child is seated in a well-supported highchair; • the child and parent are seated facing each other;

• the parent tells the child what they are having and what the expectation is; • the meal is nutritious, flavoursome and the texture is developmentally appropriate; • there is a predictable routine for mealtimes, so the child knows what to expect; • parents are attending to the child’s signals of hunger and fullness; • parents are responding quickly and supportively to help the child when they signal their needs.

Repeated exposure to rejected foods is important for preterm babies, just as it is for term babies, in order to increase acceptance.15 The wider the variety of flavours offered in the early stages of weaning, the more likely a child will accept a new food when they are older.16 Including the baby at family mealtimes is known to be beneficial for learning to eat and drink. Babies watch and mimic others and learn how to eat this way. Evidence suggests that children who join in at family mealtimes accept a wider range of foods than those who eat alone.17

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PAEDIATRIC

FUSSY EATING IN TODDLERS: IS IT JUST A PHASE? Children go through lots of phases.

To parents some of these phases can feel like an eternity with much emotion and energy expended. Fussy eating is one such phase and dietitians and nutritionists can play a vital role in supporting parents and carers through this complex stage.

It is not enough to say your child will grow out of it. That fails to recognise the impact of the fussiness on the child, the parent and the wider family. It also fails to recognise the importance of good nutrition throughout childhood for the prevention of ill health in later life. Peak bone mass is reached by the early 20s,1 so, for the prevention of osteoporosis, optimal calcium and vitamin D intake is crucial in childhood. The evidence is strong that obesity in childhood increases the risk of obesity and its associated diseases in adulthood. And the impact is not just in the long term, in 2017-18 there were 12,783 tooth extractions in the 0-5s due to tooth decay.2 Most toddlers will go through a stage of fussy eating called neophobia (the fear of trying new foods); though the length and extent of this stage varies. Fussy eating is not limited to neophobia however. Many parents will report that their children will eat a food one day and then completely refuse it the next. It is helpful for parents to learn at the point of introducing solids that fussiness is a strong likelihood, so they can be prepared for it and reduce the likelihood if possible.

Taylor et al (2015)3 states, “Picky eating (also known as fussy, faddy, or choosy eating) is usually classified as part of a spectrum of feeding difficulties.

It is characterised by an unwillingness to eat familiar foods or to try new foods,

as well as strong food preferences. The consequences may include poor dietary variety during early childhood. This, in turn, can lead to concern about the nutrient composition of the diet and, thus, possible adverse health-related outcomes. There is no single widely accepted definition of picky eating and, therefore, there is little consensus on an appropriate assessment measure and a wide range of estimates of prevalence.”

Aliya Porter, RNutr (Public Health), Porter Nutrition (freelance) Aliya is a Registered Nutritionist with experience in the voluntary sector, NHS and private practice. She has a special interest in family nutrition.

Aliya runs Porter Nutrition, focusing on healthy eating as part of normal life: www. porternutrition. co.uk

CAUSES OF FUSSY EATING TO RULE OUT FIRST

Without a clear definition, how should we advise parents? Firstly, we need to rule out other causes of the fussiness and refer to the GP if there are any concerns.

These include but are not limited to: • infection – eg, if the child has a fever or a rash or a runny nose; • constipation – using the Bristol Stool chart, get the parents to tell you what their stool is like and the regularity; • reflux – sometimes the child will have had this problem before starting solids, so ensure a full history is taken, although most reflux in babies does not persist beyond one year; • symptoms in addition to the fussiness, including frequent vomiting, regurgitation of food and re-swallowing, persistent cough, pain in the throat; • other stomach pain – this covers a range of issues including coeliac disease;

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

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PAEDIATRIC • allergies and intolerance – if the parent has seen patterns in the food behavior, eg, rashes, coughing, sickness, it is helpful to rule out allergies; • autism – sometimes autistic children can have more sensitivities to food than other children. Autistic children need additional support with their fussy eating due, in part, to the heightened sensory awareness, including taste, touch and smell of foods.

Once such causes have been ruled out and dealt with, or are being dealt with, it is important to establish the severity of the fussiness. Some parents will report that their children are fussy, but when questioned further, it is apparent that the child is consuming adequate variety across the food groups, is gaining weight along their centile and is healthy, active and has good bowel movements. It is key not to dismiss parents in this position because it may be that the child’s food habits are causing strain on the family all the same.

Listen to them and encourage them to continue to be a role model for good nutrition, offer new foods and to allow their children to experiment.

If children are cutting out whole food groups and are not getting the range of nutrients needed and/or they are not gaining weight adequately, or have little energy, then giving support to parents is crucial.

WHAT CAN WE DO TO SUPPORT PARENTS?

Firstly listen. As with any nutritional counselling, build rapport with the family and gain a full understanding of the situation. It is helpful to ask the following questions: • Who does the child spend time with at mealtimes? Are there different caregivers at different times and do they have different strategies around food?

• Are any other family members, adults or children particularly fussy with their food?

• Which foods will the child eat and which won’t they eat? Do they eat different foods in different settings, eg, is grandma’s chicken acceptable but mum’s isn’t?

• Are there specific ways they like their food prepared/cooked/presented? (For example, shape of the veg, how soft it is, whether it’s touching something else on the plate) 16

• How long has the fussy behaviour been going on?

• What do mealtimes look like? Does the whole family sit at the table? Does the child sit at the table? What happens when they get down from the table?

• Which toys, TV characters, etc, does the child like? (This can help with motivation.)

It is unhelpful to play the blame game. There are all sorts of reasons why children choose not to eat the food they have in front of them. Sometimes the discussion can reveal family challenges which need to be handled sensitively; other times it is just the main care giver who needs support to feel empowered to make changes.

Strategies which can be used to help parents include the following: Make mealtimes fun Turn off the TV, phones and music and give the child attention, eg, asking what their day was like. Avoid a battle over eating. If they get down from the table, don’t get them back again, take the food away and wait until the next meal/ snack.

Give the child choice Even at a very young age we can give children some choice. Which shape pasta to have – penne or fusilli – or which vegetable to cook out of two options. This helps them feel involved and not passive.

Give them control Control over where they sit at the table, which plate, cup and cutlery to have, how the food goes on the plate, how the food is cut. It might seem counterintuitive to carers to do this because they may feel like the whole process has been the child dictating mealtimes, however this is about specific control: control over the things they can control and building independence in other ways, so it is not all about getting control over which food they actually eat.

Get them involved . . . . . . in growing food, shopping and food preparation. Even under one-year-olds can help with some things: bread dough is just like

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PAEDIATRIC Figure 1: Steps to trying food

playdough; they could use a spoon to spread the tomato sauce onto homemade pizza. With the growth in online food shopping, children have less involvement in food shopping. It can be helpful to write a list for the top-up shop with pictures and let the child help put things in the basket. They could even choose which fruit or veg to get in the supermarket. Older children could be challenged to make a rainbow with their veg choices.

Use different rewards Lots of rewards are food related. Help parents to find alternative rewards. Children can be rewarded for trying a food, but they shouldn’t be rewarded for eating all their food. In this stage, you can also help parents to use positive language for all foods, not just the yummy chocolate cake, but the yummy carrots too.

Other strategies to consider • Help parents to avoid getting their children to eat their main meal before they can have their pudding, otherwise the child will see the main course

as something to endure before the satisfaction of the pudding.

• Putting one piece of everything on their plate and letting them ask for more. For some children having food on different plates can be helpful. Parents need to know that the child doesn’t have to have eaten everything on their plate before they ask for more, but each food does need to be on the plate. There are different levels to this (see Figure 1). Depending on the severity of the fussiness, these stages may take a couple of meals each or weeks each. A child should never be bribed or forced to eat the food, as this leads to further problems down the line.

• Consider whether vitamin and mineral supplements are necessary.

CONCLUSION

Fussy eating is a complex stage in the life of many toddlers. Each child is different. Supporting families takes time and requires adapting to their needs. Empowerment is really important.

Involving the child in the process and giving them control can help.

A wealth of useful dietetic resources for all dietitians and nutritionists

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PUBLIC HEALTH

PLANT-BASED DIETS A move away from processed meat towards plant-based foods is growing in popularity. The number of vegans in Great Britain quadrupled between 2014 and 2019, with vegans making up 1.16% of the population in 2019.10 This article reports on the nutritional considerations of plant-based diets.

Plant-based diets are defined by the low frequency consumption of animal food and by consuming mostly or solely foods that come from plants. These include fruit, vegetables, grains, pulses, legumes, nuts and meat substitutes such as soy and new novel food products with a focus on healthy wholefoods, rather than processed foods. The drive towards a more plant-based diet is fuelled by a combination of health, environmental, economic, religious and ethical reasons.

Consumers understand and use the term ‘plant-based’ diet in different ways, from complete avoidance of animal and animal-related products to the occasional consumption of meat, fish, or dairy products. Similarly, consideration should be given to the type, quality and frequency of plant foods consumed, the degree of over processing and what else is eaten in the diet.

CARDIOVASCULAR AND OTHER BENEFITS

Numerous studies have found plantbased diets are associated with lower risk of cardiovascular outcomes and improved lipid profile.1 Randomised

clinical trials have demonstrated that replacing red meat with nuts, legumes, and other plant-based protein foods reduces levels of total and low-density lipoprotein cholesterol.2 The low saturated fat and high unsaturated fat contents of a healthful plant-based diet may lower CVD risk by improving the blood lipid profile and also through its potential anti-inflammatory effects. Replacing saturated fats with polyunsaturated and monounsaturated fats may also enhance insulin sensitivity and prevent Type 2 diabetes, possibly through altering cell membrane fatty acid composition and, thus, cell membrane function, moderating gene expression and enzyme activity and mediating the inflammatory response.

Plant foods, such as wholegrains, fruits, vegetables, vegetable oils, nuts, tea, coffee, and cocoa, are also rich in polyphenols, flavonoids, lignans, phenolic acids and stilbenes, which are natural bioactive compounds produced by plants as secondary metabolites.

Their antioxidant capacity protects against oxidative stress. Polyphenols

Ruth James RD MSc SENr MBA Freelance Dietitian and Sport Nutritionist Ruth was previously a Clinical Gastro Dietitian and NHS Manager both within and outside dietetics.

She is now a Registered Sports Nutritionist who is passionate about helping elite and recreational sports people realise their full performance potential.

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

Table 1: Examples of plant-based diets Lacto-vegetarians Ovo-vegetarians Lacto-ovo-vegetarians Semi-vegetarians (or flexitarians) Pescetarians

Vegans

Eat dairy foods but exclude eggs, meat, poultry and seafood.

Include eggs but avoid all other animal foods, including dairy.

Eat dairy foods and eggs but not meat, poultry or seafood.

Occasionally eat meat or poultry.

Eat fish and/or shellfish.

Don’t eat any animal products at all, including honey, dairy and eggs. Many shop-bought ready-made products may contain animal ingredients, so the labels of all manufactured products need to be read carefully. www.NHDmag.com December 2019 / January 2020 - Issue 150

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PUBLIC HEALTH might also contribute to improved cardiovascular health through their roles in inhibiting platelet aggregation, reducing vascular inflammation and improving lipid profile.

A healthful plant-based diet is also rich in other antioxidant nutrients such as vitamins C and E, beta-carotene and potassium, which has been shown to reduce blood pressure and lower stroke risk through its beneficial effects on endothelial function and vascular homeostasis.

Also, magnesium found in plant-based foods has been associated with improved cardio-metabolic outcomes due to its effects on glucose metabolism and insulin sensitivity and its anti-inflammatory, vasodilatory and anti-arrhythmic properties.

The gut microbiome – the complex community of microorganisms that reside in the human gut – metabolises otherwise indigestible dietary substrates to potentially influence the cardiovascular health of the human host. Plant-based diets differ from animal-based diets with respect to many other microbe-dependent metabolic pathways, including increased metabolism of fibre and polyphenols and decreased metabolism of bile acids and amino acids, which could mediate their inverse associations with cardiovascular end points.

Research suggests that people who eat primarily plant-based diets tend to have a lower body mass index (BMI) and lower rates of obesity, diabetes and heart disease than those who eat meat.3 Plant-based diets (especially vegan diets) may also help people prevent or manage diabetes by improving insulin sensitivity and reducing insulin resistance.4 The risk of diverticular disease too, has been found to be lower in vegetarians (31%) and even lower in vegans (72%) when compared to meat eaters.5

Another benefit is that people following plantbased diets and consuming a wide variety of fruits, vegetables and pulses are generally likely to find it easier to meet their five-a-day target and eat a diet high in fibre and complex carbohydrates. They are also likely to have good intakes of the vitamins and minerals present in fruit and vegetables, including folate, vitamin C and potassium, all of which are important for good health.

just one third of the fertile land, fresh water and energy of the typical British meat-anddairy-based diet. With meat and dairy being the leading contributor to greenhouse emissions, reducing animal-based foods and choosing a wide range of plant foods can be beneficial to the planet and our health.6 There is growing concern that industrial meat production can contaminate natural resources, including rivers, streams, and drinking water and that the raising of livestock can lead to the loss of forests and other land that both provide valuable carbon sinks.

SUSTAINABLE EATING

Protein: Some people may have concerns about getting enough protein from a plant-based diet.

However, there is a wide variety of plant-based

In the UK, it is estimated that well-planned completely plant-based, or vegan, diets need 20

NUTRITIONAL CONSIDERATIONS

Plant-based may not always mean ‘healthy’, particularly when it comes to processed and packaged foods. Technically, products such as refined sugar, white flour and certain vegetable fats can all be labelled ‘plant-based’ as they are vegetarian, but this does not mean that they should make up the bulk of a healthy diet. Also, if plant-based diets are not well planned, this may lead to a deficiency in the intake of some nutrients.

When following a plant-based diet, there are some key nutrients to focus on to avoid deficiency, as certain nutrients are not found very easily, or at all, in plant foods. These may need to be sourced from fortified foods such as fortified plant milks, spreads and cereals.

Vitamin B12: Most people get vitamin B12 by eating animal products. The only reliable plant sources of vitamin B12 are fortified foods (some breakfast cereals, yeast extracts, soya yoghurts and non-dairy milks.) and supplements.

Recommend eating fortified foods at least twice a day, aiming for 3mcg of vitamin B12 a day, or take a supplement, 10mcg daily or at least 2000mcg weekly.

Iron has lower bioavailability in plants than meat. Plant sources of iron include dried fruits, wholegrains, nuts, green leafy vegetables, seeds and pulses. Combine citrus and other vitamin C sources with plant-based sources of iron to increase absorption.

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PUBLIC HEALTH sources of protein, including beans, lentils, chickpeas, seeds, nuts and nut butters (eg, peanut butter) and tofu. Eggs, and dairy are also good sources (if appropriate). Meat substitutes such as vegetarian burgers, soya sausages and other meat alternatives can be useful for those adapting to a plant-based diet and can provide a source of protein. However, as with any processed foods, these can often be high in salt and fat, so should be used in moderation. These products may contain animal ingredients such as eggs, milk derivatives and honey, so careful label reading is necessary if following a vegan diet.

content of the soil, which is variable. Foods grown closer to the ocean tend to be higher in iodine. The iodine content of seaweed, for example, is variable and sometimes too high. Guidance is not to consume sea vegetables more than once a week.8

Omega-3 fatty acids: These are commonly found in oily fish. However, if not eating fish, plant sources of omega-3 include walnuts, flax (linseed), hemp seeds, chia seeds and soya beans. Oils such as hemp, rapeseed and flaxseed oil provide essential omega-3 fats. Research shows, however, that the body is slow at converting omega-3 ALA to the more active EPA and DHA molecules, so supplements should be considered. A range of plant-based omega-3 supplements is available.

Selenium: Concerns have been raised about the selenium status of non-meat eaters, as the consumption of red meat is a major determinant of serum selenium.9 Plant sources of this mineral include grains, seeds and nuts. Just three Brazil nuts daily will provide you with half your daily requirement of selenium.

Calcium: Whilst the calcium intake for vegetarians is similar to that of meat eaters, the intake of calcium by vegans is much lower.7 Fortified plant-based milk alternatives, dried fruit, figs, nuts such as almonds, leafy green vegetables, red kidney beans, sesame seeds, tahini and tofu, are all good choices.

Vitamin D: Plant-based sources of vitamin D include sun-exposed mushrooms and fortified foods such as vegetable spreads, breakfast cereals and plant-based dairy alternatives.

Since it’s difficult to get enough vitamin D from food alone, everyone should consider taking a daily supplement of 10mcg/day during the autumn and winter months. Some vitamin D supplements are not suitable for vegans. Vitamin D2 and lichen-derived vitamin D3 are suitable.

Iodine: The main sources of iodine in our diet are dairy products and fish, so vegetarian and vegan diets may be deficient. Some plant-based drinks, such as soya, oat and rice, may be fortified with iodine, so it is wise to check labels. The iodine content of plant foods also depends on the iodine

Zinc: Phytates found in plant foods, such as wholegrains and beans, reduce zinc absorption.

Good sources of zinc-containing foods include fermented soya such as tempeh and miso, beans (soak dried beans then rinse before cooking to increase zinc absorption), wholegrains, nuts, seeds and some fortified breakfast cereals.

MEAT SUBSTITUTES

Plant-based meat alternatives (PBMAs) have entered the market designed to mimic the taste and experience of eating meat. These are aimed to appeal to a broader consumer base than the relatively smaller vegan or vegetarian demographic, which had traditionally been the target of animal product alternatives. PBMAs, however, need further investigation for their health benefits and carbon footprint.

Another line of products on the horizon is laboratory-grown (or cultured) meat, poultry and fish, which uses cell-based technologies to culture and grow cells from animals, producing animal products without raising and slaughtering the animal.

SUMMARY

Eating a diet higher in plant foods and lower in animal products can have many health benefits, including a lower risk of heart disease and diabetes and encouraging weight management.

Plant-based diets are seen to be environmentally sustainable too. Following a plant-based or vegan diet may challenge some micronutrients (iron, zinc, vitamin B12, calcium and omega-3s) and complete protein sources, making careful consideration and planning a requirement.

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Meeting nutritional needs in critically ill patients JUST BECAME EASIER.

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NUTRISON PROTEIN INTENSE is the newest addition to our high protein range – the first and only whole protein tube feed, high in protein, that fully meets critical care guidelines.1–5 Accurate at time of publication September 2019.

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Nutrison Protein Intense is a Food for Special Medical Purposes for the dietary management of disease related malnutrition in critically ill patients and must be used under medical supervision.

References: 1. Singer P, et al. 2019; 38(1):48–79. 2. McClave SA, et al. 2016; 40:159–211. 3. Kreymann KG, et al. 2006; 25:210–223. 4. Dhaliwal R, et al.

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

CLINICAL

NASOGASTRIC TUBE FEEDING: AN OVERVIEW Nasogastric (NG) feeding is the most common method of providing short-term (generally less than 30 days) artificial nutrition support. This article looks at considerations and management of feeding with an NG tube (NGT).

In my career to date, I am aware of one never event that happened in relation to a misplaced NGT. As a result, I am extremely mindful of ensuring all checks are completed to confirm NGT position before it is used.

An NGT is a tube inserted through the nose and into the stomach via the oesophagus. It is used for administration of fluids, medication, nutrition, gastric aspiration and decompression. The size of NGTs used for feeding should be between 6 and 12 French. In line with National Patient Safety Agency (NPSA) guidance, NGTs used for feeding should be radio-opaque along their entire length, be CE marked and have external visual length markings.1 NICE 2006 guidelines state that NG feeding should only be initiated in people who are malnourished or at risk of malnutrition and who have inadequate or unsafe oral intake and a functioning accessible GI tract.

Following the NPSA 2011 alert, before a decision is made to insert an NGT, an assessment should be undertaken to identify whether NG feeding is appropriate for the patient and the rationale for any decision should be recorded in the patient’s medical notes.

Following NICE guidance, NG feeding should be stopped when the patient is established on adequate oral intake.2 If the individual is likely to require long-term enteral feeding then they should be considered for gastrostomy feeding.

Louise Edwards Community Team Lead/Specialist Dietitian

TO FEED OR NOT TO FEED?

Enteral tube feeding is considered to be a medical treatment and, thus, initiating or withholding nutrition is, therefore, a medical decision which is always made taking the wishes of the patient into account. 3 Following the NPSA 2011 alert, ‘the decision to insert an NGT for the purpose of feeding must be made following careful assessment of the risks and benefits by at least two competent healthcare professionals, including the senior doctor responsible for the patient’s care’. The dietitian is generally one of these healthcare professionals.

For those individuals with capacity, the purpose of the insertion of an NGT should be explained to the patient along with the risks associated with it.

Following this discussion, the patient should be allowed time to consider their decision and consent if they wish the procedure to go ahead.

Where individuals demonstrate a lack of capacity, a best-interest decision should be made by the multidisciplinary team responsible for the patient’s care. A best-interest meeting may need to be coordinated involving the patient’s next of kin, an advocate, or an independent mental capacity advocate (IMCA).

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

www.NHDmag.com December 2019 / January 2020 - Issue 150

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CLINICAL Table 1: Common conditions that result in NG feeding Swallowing disorders because of neurological conditions Preoperative nutritional support Cachexia Chronic infections Malabsorption Lowered consciousness level Table 2: Contraindications for NG feeding Maxillofacial disorders Unstable cervical spinal injuries Nasal/pharyngeal/oesophageal obstruction or ulceration Choanal atresia Tracheoesophageal fistula Oesophageal/pharyngeal pouch Oesophageal strictures or other abnormalities of the oesophagus Oesophageal tumours or have undergone oesophageal surgery Basal skull fractures Oropharyngeal tumours or have undergone oropharyngeal surgery Post laryngectomy Actively bleeding oesophageal or gastric varices Gastric outflow obstruction Intestinal obstruction This list is not exhaustive, adapted from NNNG, 2016.15 INSERTION OF AN NG FEEDING TUBE

NGTs are commonly inserted by doctors, nurses and allied health professionals. The healthcare professional placing the tube should have completed training and demonstrated and achieved a competency in NGT insertion in line with the trust’s policy.3,4 NGTs are commonly placed at bedside, but there may be circumstances where radiology supports with placement.

Misplaced NGTs are a contributing cause of never events. This is in relation to the introduction of fluids, or medication into the respiratory tract, or pleura via a misplaced NGT (or orogastric tube).

Never events are considered ‘wholly preventable where guidance or safety recommendations, which provide strong systemic protective barrier, are available at a national level, and should have been implemented by all healthcare providers’.5 24

A review of never events from NHS England and NHS improvement for this year 1st April to 31st August, found 11 events of misplaced NG feeding tubes. With these incidents, feed was administered when the NG tube was in the respiratory tract. The NPSA alert 2016 titled Nasogastric tube misplacement: continuing risk of death and severe harm, found that the reasons for which never events occur in relation to NGT misplacement are: • misinterpretation of X-rays by medical staff who had not received the competency-based training required by the 2011 NPSA alert; • nursing staff error with pH testing; • unapproved tube placement checking methods; • communication failures resulting in tubes not being checked.

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CLINICAL It is possible that the patient may not be symptomatic from an NGT being inserted into the airway for several hours post placement and after multiple feedings.6 Confirming the position of the tip of the NGT is essential, since the tube may be displaced even when its external appearance (outside the face) remains unchanged.7 Checking the position of the NGT is paramount to prevent harm. BAPEN recommends repeat placement checks of the tube before administering each feed, before giving medication and at least once daily. NNNG 2016 also recommends pH testing following episodes of vomiting, retching or coughing. When there is evidence of tube displacement (ie, length of tube at nostril has changed), then a check of the placement of the tip of the NGT is required. Any new or unexplained respiratory symptoms, or a reduction in oxygen saturation, would also be indicative of an NGT placement check.4 Throughout history, different methods have been used to confirm position of the NGT. NPSA 2011 conducted a systematic review to look at the different methods of checking NGT position so that recommendations could be made as to the recommended approach of confirming position.

The NPSA recommend that pH testing is the first-line method for confirmation of NGT placement. NICE 2006 guidance reiterates that testing gastric aspirate with pH-graded paper is first line for confirming NGT placement with an X-ray being taken if necessary. The pH reading must be 5.5 or below before feed, fluid or medication can be administered via the NGT.8 pH testing is four times less expensive than X-ray confirmation.9 Local protocols should be in place for ‘how to proceed when the ability to make repeat checks of the tube position is limited by the inability to aspirate the tube, or the checking of pH invalid because of gastric acid suppression’.2 A method previously used for confirming NGT position was auscultation or the ‘whoosh’ test. This is where a stethoscope was placed over the epigastrium to listen for a ‘whoosh’ sound as air is syringed through the NGT.7 This method falsely indicated gastric position of NGTs,10 as sounds may be transmitted to the epigastrium

when the tube is positioned in the lung, oesophagus, stomach, duodenum or proximal jejunum.6 Testing of NGT aspirate with litmus paper was another method used. It was thought that if blue litmus paper turned pink with the NGT aspirate then it would indicate that the aspirate was acidic and, thus, suggest gastric placement of the tip of the NGT. However, blue litmus paper is reported to turn pink with a pH of 6 or 7 and, therefore, cannot distinguish between gastric or bronchial aspirates.11 Other methods for confirming NGT position include biochemical markers with PH testing, capnography and electromagnetic tracing, etc.12 CONSIDERATIONS FOR DISCHARGE

In some circumstances, the patient may be discharged home to continue with NG feeding.

Such examples could be palliative NG feeding and preoperative nutrition support, etc. As I have highlighted above, misplacement of an NGT can be fatal and, therefore, prior to discharge, a full multidisciplinary supported risk assessment should be made and documented before the patient is discharged from acute care to the community.1 SECURING THE NGT

A hypoallergenic tape should be used to secure the NGT to the patient’s nose or cheek to reduce risk of displacement.4 If there is repeated displacement of the NGT, a nasal retention device may be considered.

Another fixation device to discourage patients from pulling on their NGT and to aid in securing it in position at the nostril, is a nasal bridle. Reports show that 40% of NGTs are dislodged.13 A nasal bridle is an effective way of securing a patient’s NGT, retaining the provision of nutrition to the patient. Most Trusts have their own local policy for the criteria necessary in order for patients to meet NGT placement (eg, pulled out two NGTS within 48 hours). There are considerations for when a nasal bridle would be contraindicated, such as restlessness and agitation leading the individual to still pull at the tube.14 Capacity and ethics need to be considered when deciding if a nasal bridle is appropriate.

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25

80

This material is for HCP use only.

79%

Nutramigen with LGG : shown to provide 44% long-term cost effectiveness to the NHS for the dietary 24% 18% management of cow’s milk protein allergy (CMPA) ®

60 40 20 0

A new health economics study shows the cost effectiveness of Nutramigen with Lactobacillus rhamnosus (LGG®) compared to an eHCF alone as first-line dietary management for IgE-mediated CMPA.

Resilience assessed after 12 months1

80

†

79%

60 40

44% 33%

20 0

24%

Nutramigen with LGG®

18%

Infants who built tolerance (%)

Starts working to relieve ~90% if infants For first line dietary management of The unique formula of Nutramigen with CMA related colic as experienced relief ® ® IgE-mediated CMPA, Nutramigen with LGG :early as LGG proven to deliver both short and the firstisbottle within just 48 79% hours long-term clinical outcomes. Resulting in 44% cost effectiveness due to: 80

3

60

3

40 20

24%

0

Improves clinical outcomes1

Fast symptom resolution with 99% proven average clinical efficacy3† Starts working to relieve CMA related colic as early as the first bottle3

Proven to help x4 more infants return to milk sooner2‡

Releases NHS resources1 e.g. Frees up NHS appointments

2

Incidence of allergic manifestations

Reduces NHS costs

Proven to reduce incidence of 1 or more future

by Starts allergic working as manifestations 9 out of 10 ~50% infants early as the first feeding2 experienced colic relief within 48 hours2

1

0.5 0.4

eHCF

eHCF with LGG®

0.463

0.1 0.0

The study estimated the total 5 year cost of initially feeding infants with eHCF with LGG® was less than that of an eHCF alone

£

497

savings per infant over 3 years1

Reductions in incidence: Starts working as

early as the first feeding2

0.3 0.2

2× to 4× more infants safely returned to cow’s milk in 12 months or less, compared with other formulas3† 9 out of 10 infants experienced colic relief within 48 hours2

d 68% rhinoconjunctivitis

0.235

Starts working as 9 out of 10 infants Allergic manifestations combined during 3 years early as the first feeding experienced colic relief within 48 hours

Nutramigen with LGG® can save the NHS, on average:

~90% exper within j

2

12

d 61% allergic urticaria d 51% asthma Starts working as early as the first feeding

d 44% eczema

9 out of 10 infants experienced colic relief within 48 hours

2 to 4X more infants safely returned to cow’s milk in 12 months or less compared to other formulas3*

£

907

savings per infant over 5 years1*

*Projected savings over 5 years †Calculated using data on allergic reactions after oral food challenge with an eHF from table 3 of Dupont et al. 2012, as judged by the Committee on Nutrition of the French Society of Paediatrics. ‡Versus an eHCF without LGG, or formulas based on soy or amino acids.

References 1. Guest JF, Singh H Curr Med Res Opin 2019; 24:1-9 2. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913 3. Dupont C et al. Br J Nutr. 2012;107:325–338. eHCF = Extensively hydrolysed casein formula IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply.

The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® is a registered trademark of Chr. Hansen A/S. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional.

Date of preparation: October 2019 RB-M-01339

For long-term, cost effective dietary management of CMPA

co

~50%

CONSTIPATION

CONDITIONS & DISORDERS

reduction in risk of future allergies1

Starts working as early as the first feeding2 Unlike soy, rice, and amino-acid–based formulas,

Constipation is a common digestive disorder and chronic NUTRAMIGEN LGG significantly reduced the risk of developing future allergies at 3 years, including *: constipation is thought to affect (on average) around 15% of the RhinoAllergic Asthma Eczema conjunctivitis urticariato determine constipation population.1 This article will focus on how and treat it appropriately.

1

Resilience assessed after 12 months 18%

Amino Acid Formula (AAF)

9 out of 10 infants experienced colic relief within 48 hours2

Amino Acid Formula (AAF)

24%

Soy Formula (SF)

Soy Formula (SF)

68%33%

Hydrolysed Rice Formula (HRF)

61%

Extensively Hydrolysed Casein Formula (EHCF)

Hydrolysed Rice Formula (HRF) 51% 44%

Extensively Hydrolysed Casein Formula (EHCF)

44%

Constipation can be classed into different months before diagnosis and symptoms types. Functional constipation is more should be present during the last three ~ 50% 3 specifically chronic constipation with months.

However, a clinic review reduction in future allergies reduction in risk by the BMJ states that they prefer a no cause and can include slow transit ~50% of future allergies 18% constipation, outlet delay constipation, or more inclusive method to diagnose 2 tonormal 4X more infants safely returned transit constipation. Slow transit chronic constipation, ie, any patient RhinoAllergic to cow’s milk in 12 months or less urticaria Asthma compared to other formulas constipation, as *it says on the tin, is conjunctivitis when experiencing consistentEczema difficulty with contents move slower than usual through defaecation.4 68% REDUCTION 61% REDUCTION 51% REDUCTION 44% REDUCTION the colon. Outlet delay constipation is ~ 50% affected by the pelvic floor muscles, WHY DOES IT OCCUR? either from pelvic floor dysfunction Constipation tends to affect the very (when the muscles contract during young, or older population and is more RhinoAllergic conjunctivitis urticarial Asthma 61% 44% defaecation) and/or anismus68% (where the 51%common in women thanEczema men.2 25.5% 44% external anal sphincter contracts instead It is30.5% often thought that a22% lack of fluid 68% 34% 61% 51% of relaxes during defaecation). Normal can contribute to constipation, due to transit constipation, meaning68%that 61% there 51% the44%physiology of the digestive system. are no delays in colonic transit or outlet, The RhinoAllergic colon receives approximately 1.5L conjunctivitis urticarial Asthma Eczema is the most common subgroup, but is the of liquid effluent daily from the small 68% 61% 51% least clearly defined.2 intestine, with44% 200ml to 400ml excreted Functional constipation can be in ~50% the stool. The functions of the colon Reduced by diagnosed by using the Rome IV are to absorb fluid and transport waste ~50% criteria, which states it must include to the rectum, where it is expelled or two or more of the following: stored until defaecation is convenient, • straining during more than oneas well as sodium and electrolytes being fourth (25%) of defaecations; actively reabsorbed. As a result of this, • lumpy or hard stools more than stools that remain in the colon longer one-fourth (25%) of defaecations; will become drier, which can lead to • sensation of incomplete evacuation pebble-like stools and impaction if a more than one-fourth (25%) of stool becomes too large and hard to defaecations; pass through the anal canal;5 it can slow • sensation of anorectal obstruction/ colonic transit and reduce stool output. blockage more than one-fourth However, interestingly, the evidence (25%) of defaecations; for increasing fluid in the diet to relieve • manual manoeuvres to facilitate constipation is lacking.6 Not drinking more than one fourth (25%) of enough fluid tends to be more common defaecations (eg, digital evacuation, in the elderly, perhaps as a habit or support of the pelvic floor); actively reducing fluid intake to control • fewer than three spontaneous continence. bowel movements per week.3 Mobility may also be a factor, as well as independent living, as studies have The Rome IV criteria also states that found that healthy, active individuals symptom onset should occur at least six living in the community are less likely

Extensively hydrolysed casein formula (eHCF)

Soy formula (SF)

Amino acid formula (AAF)

2–4X more infants returned to cow’s milk in ≥12 months

Nutramigen LGG

2 to 4X more infants safely returned to cow’s milk in 12 months or less ompared to other formulas3*

Nutramigen LGG

Infants who build resilience (%)

1

Rebecca Gasche Specialist Dietitian, Countess of Chester Hospital NHS Trust

1

Starts working as early as the first feeding2

Unlike soy, rice, and amino-acid–based formulas, NUTRAMIGEN LGG significantly reduced the risk of developing future allergies at 3 years, including1*:

3

9 out of 10 infants experienced colic relief within 48 hours2

Rhinoconjunctivitis

Allergic urticaria

Asthma

68%

61%

51%

Eczema

44%

†

% if infants rienced relief just 48 hours3

2× to 4× more infants safely returned to cow’s milk in 2 months or less, compared with other formulas3†

79%

†

†

†

reduction in future allergies1

2 to 4X more infants safely returned to cow’s milk in 12 months or less compared to other formulas3*

Rhinoconjunctivitis

Allergic urticaria

Asthma

Eczema

REDUCTION†

REDUCTION†

REDUCTION†

REDUCTION†

Allergic urticarial

Asthma

Eczema

Rhinoconjunctivitis

34%

Rhinoconjunctivitis

68%

30.5%

Allergic urticarial

61%

Asthma

51%

25.5%

22%

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.

Eczema

44%

Other

Other

Reduced by

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

www.NHDmag.com December 2019 / January 2020 - Issue 150

27

CONDITIONS & DISORDERS Table 1: Common drugs that can cause constipation6 Antihypertensive drugs, such as clonidine, calcium antagonists and ganglionic blockers, can be linked to constipation as they reduce smooth muscle contractility.

Analgesics, such as opiates and cannabinoids, are especially notorious for causing constipation.

Antidepressants, especially tricyclic antidepressants.

Anti-parkinson, antiepileptic and antipsychotic drugs are associated with constipation due to their anticholinergic and dopaminergic actions and should be avoided or combined with the regular use of laxatives.

Oral iron supplementation frequently causes constipation and, in patients in whom iron supplementation is necessary, intravenous supplementation of iron or the addition of a laxative may be options.

Antihistamines, antispasmodics and vinca alkaloids are associated with constipation as a side effect and should be replaced.

Table 2: The amount of fibre found in certain foods14 Food

Fibre per 100g

Fibre flake/Bran cereals

13-24.5g

Wholemeal bread (2 slices)

5g

Brown rice

0.8g

Wholemeal spaghetti

3.5g

Apple

1.8g

Banana

1.8g

Broccoli (boiled)

2.3g

Carrots (boiled)

2.5g

Almonds

7.4g

Peanuts

6.4g

Sunflower seeds

6g

Peas (boiled)

4.5g

Baked beans

3.7g

Chickpeas

4.3g

to experience functional constipation than those in hospitals or similar institutions.7,8 When looking at the older population, taking into consideration chewing difficulties/dentures, the number of high-fibre foods they are able to consume may be affected.

DIETARY FIBRE

A change in diet seen in western culture is thought to have some links with the prevalence of constipation and may be a causation factor.

The increase of food processing has resulted in a lower intake of fibre.

Dietary fibre can be described as a component of food that includes ‘all carbohydrates that are neither digested nor absorbed in the small 28

intestine and have a degree of polymerisation of three or more monomeric units, plus lignin’.9 In simpler terms, it is ‘roughage’ in our diet that helps to regulate our bowel movements. Diets high in fibre have been linked to reducing the risk of diabetes and bowel cancer, as well as helping to lower cholesterol.

Historically, fibre has been broken down into insoluble and soluble, depending on the water solubility of the fibre. Insoluble fibre is roughage, as it isn’t digested and adds bulk to our stools.

Insoluble fibre consists of the structural fibres, for example cellulose, lignin and hemicelluloses, and can be found in wholegrains, wheat bran and the skins/seeds/piths of fruits and vegetables.

Soluble fibre helps draw water into our stools, as

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CONDITIONS & DISORDERS

Both soluble and insoluble fibre sources can help with constipation.

Table 3: Tips to help increase fibre in the diet

HOW TO TREAT IT

Add nuts/seeds to cereals or soups Snack on fruit/vegetables with the skins on (apples, carrots) Choose wholegrain carbohydrates Increase fibre intake gradually and ensure adequate fluids – set an alarm or use a bottle with markings on to track fluid intake throughout the day Additional beans/pulses in stews, soups Include a high-fibre breakfast cereal Include an extra portion of vegetables with main meals

well as binding to substances such as cholesterol and glucose, slowing their absorption. The natural geI-forming fibres are pectin, gums, mucilages and some hemicelluloses, and are largely found in oats, beans, pulses and the inner flesh of fruits and vegetables.2 The terms ‘insoluble’ and ‘soluble’ have, however, been discouraged in the clinical setting, with the argument that all fibrous foods contain a mixture of both these types of fibre.

Pharmaceuticals also play a role in the risk of constipation, as it is a common side effect of many drugs (see Table 1).

Many diseases, in particular neurological diseases, may contribute to constipation. These include diseases that involve the nervous system, such as diabetes mellitus and autonomic neuropathy and neurogenic bowel dysfunction in diseases such as spinal cord injury, multiple sclerosis and Parkinson’s disease.

A multifactural approach is important when treating constipation; as we can see from the causes, it is often not a ‘one size fits all’.

Fibre The Scientific Advisory Committee on Nutrition (SACN) released a report in 2015 which advised that the population should be aiming for 30g fibre/day.10 However, it is estimated that the UK population consumes around 17.2g/day of fibre for women, and 20.1g/day for men.11 Both soluble and insoluble fibre sources can help with constipation. Soluble fibre helps to increase faecal bulk, which can stimulate colonic transit, as well as producing greater bacterial growth (particularly when found in oat bran).

Insoluble fibre provides more slowly fermentable polysaccharides, which helps to maintain the microbiomes during the transit through the colon. Foods such as prunes and kiwis have been shown to help improve constipation, likely due to the combination of different fibres that the fruits contain.12,13 When increasing dietary fibre, it is important to do this gradually and alongside increasing fluids. Increasing fibre too quickly into a diet may result in more gastrointestinal symptoms. The response should be monitored, as it may take a number of days or weeks before the effects take place.

Probiotics Probiotics may also have a role in relieving constipation. Some studies have identified that certain strains of probiotics may have

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29

This material is for healthcare professionals only

NUTRAMIGEN WITH LGG : ®

PROVEN EFFICACY AT EVERY STEP* 1

NOW rapidly relieve cow’s milk allergy symptoms as quickly as 48 hours 2–4

TOMORROW successfully accelerate return to cow’s milk after 12 months of use**5

IN THE FUTURE reduce the risk of future allergic manifestations by ~50%†6

*For the management of cow’s milk allergy **vs. eHCF without LGG®, rice, soy or amino acids (p<0.001) † During a period of 3 years vs. eHCF without LGG® (p<0.001)

TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY

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.

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

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

Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be under medical supervision. Trademark of Mead Johnson & Company LGG © 2019 Mead Johnson & Company, LCC. All rights reserved. LGG ® and the LGG ® logo are registered trademark of Chr. Hansen A/S. Date of Preparation: September 2019 (RB-M-00424)

CONDITIONS & DISORDERS beneficial effects. These include lactobacillus casei, Escherichia coli and Bifidobacterium lactis, which all increase stool frequency and improved consistency, and Bifidobacterium animalis, which reduces colonic transit time.15-18 However, as most studies look at probiotics and GI health, evidence is limited and, therefore, recommendations should be made on an individual basis.

Medication As well as being the cause of some constipation, medications can help to relieve it. The NICE guidance advises the following on treating both short-term and chronic constipation:19 • Offer drug treatment with oral laxatives using a stepped approach. Adjust the dose, choice and combination of laxatives used, depending on the person’s symptoms, the desired speed of symptom relief, the response to treatment, and their personal preference.

• Initial treatment should be with a bulkforming laxative such as ispaghula.

• If stools remain hard or difficult to pass, add or switch to an osmotic laxative, such as a macrogol.

• If a macrogol is ineffective, or not tolerated, offer treatment with lactulose second line.

• If stools are soft but difficult to pass, or there is a sensation of inadequate emptying, add a stimulant laxative.

• If faecal loading/impaction is apparent, suppositories may be used.

FURTHER RECOMMENDATIONS

NICE also recommends increasing dietary fibre and fluids (especially if dehydrated), establishing a good ‘toilet routine’ and increasing activity and exercise levels, if needed. Helpful toileting routines include the following:19 • Establish a regular, unhurried toilet routine, giving time to ensure that defaecation is complete.

• Advise on responding immediately to the sensation of needing to defaecate.

• Ensure that people with limited mobility have appropriate help to access the toilet with adequate privacy.

• Ensure the person has access to supported seating if they are unsteady on the toilet.

CONCLUSION

Constipation tends to affect the very young and the elderly and is more common in women than men. Dietary fibre plays a large role in helping with the symptoms of constipation, but when increasing dietary fibre, it is important to introduce foods gradually, making sure that hydration is increased alongside. Whilst some medications can cause constipation, drug treatment (supported by NICE19) can help in the short-term, as well as for the symptoms of chronic constipation.

Coming in the February 2020 issue View it online at www.NHDmag.com

NETWORK HEALTH DIGEST

• Nutrition support in oncology

• Obesity and energy metabolism

• ONS and eating disorders • Diet and fertility

• Diet trends 2020

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31

DIET TRENDS

POPULAR LIQUID DIETS Liquid diets can be essential for certain medical purposes. However, when liquid diets are used for general weight loss, they can be unbalanced or harmful. This article will focus on the nutritional content and evidence related to five popular liquid diets.

Maeve Hanan UK Registered Dietitian Freelance Maeve is a Consultant Dietitian and Health Writer.

She 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

32

Liquid diets and meal replacements come in various forms. There are some medical indications for liquid diets, such as before or after certain types of surgery, or the use of exclusive enteral nutrition for inducing remission in Crohn’s disease. However, many liquid diets that are promoted as magic bullet solutions for weight loss, are extreme and can be nutritionally harmful.

JUICE DIETS

Juice diets involve only consuming juiced fruit and vegetables for about 3-10 days. These diets are often promoted as ‘detoxes’, ‘cleanses’ or ‘juice fasts’. But, of course, no diet can ‘detoxify’ our body, as this is done by our lungs, gut, skin and kidneys.

A popular type of juice diet is called ‘the master cleanse’ or the ‘lemoncayenne pepper diet’. This extreme diet involves consuming mainly lemon juice, cayenne pepper, maple syrup and water for 10 days. Raw juice diets are also popular, some of these involve consuming up to two litres of raw fruit and vegetable juice per day!

Because juice diets are very low in calories, they can lead to weight loss, although weight tends to be regained when normal eating is resumed.1 Juice diets also tend to be deficient in calories, protein, fat, iron, calcium, vitamin B12, iodine and selenium.

Juice ‘cleanses’ can lead to unpleasant side effects, including: bloating, cramping, diarrhoea, dizziness, low energy levels and erratic blood sugar levels. There are also health risks related to juice fasting, which is especially unsuitable for those who are nutritionally

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vulnerable, such as children, pregnant or breastfeeding women, those who are malnourished, or those who have a history of an eating disorder.

A high intake of juice may interact with certain medications (such as warfarin). It can also be harmful to undertake a diet like this for those with diabetes, liver disease, kidney disease and thyroid issues (due to high levels of goitrogens found in plant foods).

THE CABBAGE SOUP DIET

This fad diet has re-emerged many times over the years and was very popular in the 1980s. This diet involves consuming mainly (you guessed it) cabbage soup for around a week. Some fruit and vegetables or low-fat milk are also allowed on this diet.

No studies have investigated the impact of the cabbage soup diet.

However, the impact is likely to be very similar to juice diets, as this is very low in calories and provides little to no protein or fat. Therefore, it is another extreme and unbalanced approach, with the likelihood of gut irritation from the high intake of cabbage.

WATER FASTING

This usually involves only consuming water for 24 to 72 hours, although black tea and coffee are also sometimes allowed.

Water fasting for 24 hours may have similar health benefits to other types of daily intermittent fasting, such as improving metabolic health and reducing inflammation in the body.2 It has been suggested that this may be related to the ‘thrifty genotype theory’

DIET TRENDS

Liquid diets can be essential for certain medical purposes.

However, when liquid diets are used for general weight loss, they can be unbalanced or harmful.

Juice diets involve only consuming juiced fruit and vegetables for about 3-10 days. that suggests humans have evolved to thrive during cycles of fasting and feasting.3 Fasting might also have benefits for healthy aging, as short periods of fasting may improve the way our body recycles damaged parts of cells (which is known as ‘autophagy’).4-5 However, we don’t have much evidence about how this impacts health in the long-run and many of the studies have been carried out in animals.

Some studies have also highlighted harmful side effects of water fasting, including nausea, low energy levels, headaches, high blood pressure, low sodium levels and even serious cases of dehydration.6 The risk of harm from this diet increases depending on the length of the water fast.

Overall, water fasting is likely to be an unnecessarily extreme and risky approach for most people.

LOW-CALORIE MEAL REPLACEMENT SHAKES

Meal replacement shakes can be used as the sole source of nutrition, or to replace one or two meals per day.

The nutritional content of these shakes varies between different products. Some can be low in fibre and it is safe to say that they can’t provide the range and combination of phytonutrients found in wholefood. Meal replacement shakes also can’t replicate the ‘food matrix effect’,

which is the way that the structure and nutrient content of food interacts with each other. For example, consuming omega-3 supplements, or a product which is fortified with omega-3, isn’t seen to have the same health benefits as, eating oily fish.7 Some meal replacement shakes use certain sugar alcohols (polyols) as a low-calorie sweetener. While not inherently bad, this may cause gut issues or trigger IBS symptoms in some people.8 Very low-calorie diets usually involve consuming meal replacement shakes and soups to provide around 800 to 1200 calories per day for up to 12 weeks. These are associated with significant weight loss up to a year after the diet has taken place (although some weight tends to be regained).9 These diets, however, may have useful applications in Type 2 diabetes. For example, the DiRECT trial investigated whether following a very low-calorie diet could put people with Type 2 diabetes into remission.10 This involved consuming only 850 calories per day, in the form of four meal replacement shakes or soups, for three to five months, followed by food reintroduction and ongoing healthy lifestyle support. By the end of the trial, almost 50% of participants had gone into remission and the success rate rose to 86% for

www.NHDmag.com December 2019 / January 2020 - Issue 150

33

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DIET TRENDS those who lost more than 15kg of weight. This is a promising new area, but it is important to remember that this diet is very restrictive, so it wouldn’t be appropriate for many people and a lot of support is needed to follow the diet in a safe way.

A very low intake of calories may slow down metabolic rate due to processes like adaptive thermogenesis and relative energy deficiency (which is often referred to as ‘starvation mode’).11-12 A slightly less extreme approach is replacing one to two meals per day with a meal replacement shake or soup. This has been found to promote weight loss and lead to improvements in blood pressure, cholesterol, blood glucose and insulin levels, when compared with a traditional caloriereduced diet.13 Some people find meal replacement shakes to be a convenient way to reduce their calorie intake. However, they can also be expensive, especially when used over a long period of time.

They also do not replicate all of the goodness found in wholefood, and are not advisable for those who struggle with disordered eating.

NEW GENERATION MEAL REPLACEMENT SHAKES

In the last five years a new type of meal replacement shake has emerged aimed at busy people who want a nutritionally complete meal in the form of a shake. So, the focus isn’t on weight loss, but convenience and sustainability.

Examples of these include Huel and Soylent.

These shakes tend to have a good nutritional profile and are suitable for many dietary needs. For example, they are free of common food allergens and are suitable for vegans and

vegetarians. However, as mentioned above, these are unlikely to match the nutritional benefits of a diverse wholefood diet. There is also little to no evidence about the health impact of these specific products. Although one randomised controlled trial from 2016 reported a favourable impact of Soylent on the balance of gut bacteria in 14 participants.14-15 For more information about Huel, go to Alice Fletcher's article in issue 137 (Aug/Sep 2018, www.nhdmag.com/nhd-articles/archive.html).16 CONCLUSION

Faddy liquid diets like juice diets and the cabbage soup diet are not nutritionally balanced and are likely to cause gut issues.

There may be some benefits to a 24-hour water fast for some people, but this is a new area of research and there can be serious side effects to water fasting.

Low-calorie meal replacements shakes and soups may be useful for some people who are trying to lose weight, and more research is emerging related to their use as part of very low-calorie diets to promote diabetes remission.

However, close support and monitoring is needed with this.

The new generation of meal replacement shakes (which don’t focus on weight loss) are nutritionally balanced convenient options.

However, using meal replacements of any kind is unlikely to match the food matrix effect of wholefood. Furthermore, getting into the habit of drinking meals rather than eating food may encourage an unhealthy relationship with food for some people, especially those with a history of disordered eating.

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SOCIAL CARE

THE CENTRAL ROLE OF CARE CATERERS IN DELIVERING QUALITY, SAFE, PERSON-CENTRED MEALTIMES In any home, the kitchen is at the heart of our social, physical and emotional wellbeing. It nourishes us, stimulates happy memories of times gone by and encourages us to come together with others and share conversation, company and experiences. This is no different for residents of care homes up and down the country.

In the past two years, I have been honoured to be an invited speaker at the Scottish NACC (National Association of Care Caterers) conference. Care caterers have a vital role to play in enabling our service users to enjoy, look forward and live life to the full. They are core team members, to be included in meetings and conversations about care planning; getting to know each person in our care; and developing a holistic understanding of how to keep residents happy and well.

In care homes up and down the country, new residents are being admitted probably feeling a bit anxious, homesick, lost and upset; maybe they’ve been recently bereaved, or have been discharged from hospital without having the chance to see their old home. One of the first people who can help to offer some comfort, show interest in them and a provide a warm welcome, will be the chef.

After the initial admission process and maybe a cup of tea, what would your first thought be? “I wonder what’s for lunch – I’m starving!” “It smells as though they’re cooking fish and chips today – my favourite!” “I don’t think I could face much to eat – maybe some soup?” Most admission documentation will (hopefully) include a conversation about an individual’s food and drinks preferences. It would be all too easy to take that at face value, but taking time to tease these out can reap greater rewards. A good care chef will know that sometimes people will prefer specific brands (tomato soup springs to mind!); residents might

prefer the way food is cooked in the home, eg, macaroni cheese, rather than by the person they were living with before admission. It can take a few weeks to get to know someone’s true likes and dislikes.

Our tastes can of course change due to a variety of factors, including medication, oral health, available choice of food and drinks and illness. We all have different preferences/comfort foods when we are poorly, so our care chefs need to know these for each resident too, helping them to regain their strength and health quickly.

Food presentation and the type of crockery, glassware and cutlery can also impact on whether people choose/are able to consume meals and drinks. Using small shot glasses or ramekins to serve minidesserts and knowing which type of cup someone prefers to drink from, are small factors, which can encourage improved eating and drinking. Choosing bright bold coloured products, which stand out against a plain white tablecloth can help service users to help themselves, while occupational therapy colleagues can advise on purchasing individualised adaptive aids and equipment to enable greater independence and enjoyment of mealtimes.

Evelyn Newman Nutrition and Dietetics Advisor: care homes NHS Highland Award winning dietitian, Evelyn Newman, is well known throughout the profession for her writing, volunteering with the BDA and innovative work.

She currently holds a unique role in The Highlands.

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

CHALLENGES AND DIFFICULTIES

Some of the major problems I’ve noticed over the past six years working with care home cooks is their lack of nutritional knowledge or experience of working in care homes; their inability to prepare a range of texture modified meals and www.NHDmag.com December 2019 / January 2020 - Issue 150

37

SOCIAL CARE ask a colleague or family member to feed you your next meal to give you insight. If care cooks struggle to offer a good variety of tasty, safe, person-favourite meals, the knock-on effect on care staff workload will be negatively impacted.

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snacks and the lack of cover for them to have time off. The NACC website1 offers a great selection of information and training opportunities and the Care Inspectorate Food and Fluid Hub2 includes practical YouTube clips, menu planning ideas, links to the IDDSI website and apps. In Highland we have a multi-agency group of staff working with the University of Highlands and Islands, who are trying to develop a pilot model or care cook training. This will provide a career opportunity that many school leavers or existing cooks may have never previously considered. This will result in a higher standard of motivated, capable catering staff who are more able to support the high-quality meal service that our frail elderly clients deserve.

We have increasing numbers of residents and day service users who require texture modified diets to keep them safe and well.3 As people live longer with dementia, and other similar neurological conditions, they may experience increased challenges in eating well. People with dysphagia have a 50% increased chance of being malnourished and a 70% chance of developing dehydration if we donâ&#x20AC;&#x2122;t have well-motivated skilled caterers to help to address this.

How often are menus updated by the cook where you work? Are they very person-centred and appetising? How much variety is offered to prevent menu fatigue? How many people need assistance to eat and drink? It is very challenging to experience this and I would encourage you to 38

We all know the implications of malnutrition and dehydration and the likely need for prescriptions.

In the Highlands, we proactively promote a foodfirst model of nutritional care, which requires catering staff to work closely with residents and service users to coproduce opportunities for varied person-centred meals, snacks and drinks. Staff have described how this has helped reduce the incidence of UTIs, constipation, weight loss, headaches and falls. The consequence of this is to reduce the need for clinical referrals (dietetic and GP), prescriptions for antibiotics, laxatives and oral nutritional supplements,4 which helps to reduce wasted food and frees up care staff to spend more time interacting with residents, instead of administering medicines and personal care. Not surprisingly, residents are noticeably happier and healthier.

The risks of not getting care catering right for residents must be recognised and mitigated against. Incidents and consequences of death by aspirating unsafe textures, reactions to allergens, dehydration and weight loss, are all avoidable.

The risk of not having the cooks with the right training and skills must also be a consideration, plus making appropriate arrangements for cover when the chef is off or during periods of vacancy, which happens all too frequently in the care sector.

Having frozen meals, especially for specialist diets, can ensure that people eat well, whether the meals are cooked inhouse or bought in from an external supplier. Many of the care settings in Highland safeguard against risks by purchasing meals from private catering companies and many of our careat-home service users benefit from a contract with Apetito5 meals. This is positively evaluated, especially with the added challenges of our remote and rural geography, which is often compounded during challenging weather conditions.

We all have a duty to help safeguard people from nutritional risk and as dietitians we can also use our networks and influencing skills to develop and share innovative, transformational approaches to all our care catering settings.

www.NHDmag.com December 2019 / January 2020 - Issue 150

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IS ORGANIC THE HEALTHIER OPTION?

FOOD & DRINK

‘Organic’ is a common buzzword within the wellness sphere. This is often used to suggest that a food is superior in terms of quality or healthfulness, but is this actually the case?

Organic food production focuses on the sustainability of soil, the wider environment and human wellbeing.1 This uses farming and production methods adapted to local conditions, which promote biodiversity.1

Organic food legislation varies between countries. In the EU, the ‘EU organic logo’ can be used if at least 95% of the agricultural ingredients meet the standards of the EU Organic Regulation.2 The EU has passed new legislation that will come into force on 1 January 2021.25 Examples of the changes that will be made include: • new rules for producers which will make it easier for smaller farmers to convert to organic production; • new rules on imported organics to ensure that all organic products sold in the European Union are of the same standard; • a greater range of products that can be marketed as organic.

If a product carries the Soil Association organic logo then it has been certified to meet the standards of the EU Organic Regulation, as well as a set of higher standards devised by the Soil Association.3 Detailed guides can be found at: www. soilassociation.org/our-standards.

There isn’t always a big difference between conventional farming and organic farming. For example, pesticide use is reducing in conventional farming in many countries and strategies such as crop rotation are often used in both types of farming.4 In some countries, organic products differ because they aren’t produced using hormones and antibiotics and cattle are more likely to be grass-fed.

In the EU, there are laws against using hormones and antibiotics as a routine part

of food production and the majority of cattle are grass-fed.5,6 Similarly, synthetic pesticides may be used in some cases with organic farming; although this is less likely than with conventional farming.

NUTRITIONAL CONTENT

Some minor nutritional differences have been found between organic and conventional produce. For example, systematic reviews found that protein levels may be slightly higher in conventional produce and phosphorus may be slightly higher in organic produce.7,8 However, these small differences are not thought to be clinically meaningful.7,8 Similarly, a meta-analysis of organic versus conventional milk, found higher levels of omega-3, iron, vitamin E and conjugated linoleic acid (CLA) in organic milk, but lower levels of iodine and selenium.9 However, these differences were relatively small overall. Furthermore, the authors acknowledged that the main reason for this difference was related to whether the cattle were grass-fed, rather than due to organic production overall.

Seasonal and geographical differences are also thought to have a big impact on the nutritional content of milk.

These authors also conducted a meta-analysis to compare the nutritional content of organic versus conventional meat.10 This found similar levels of saturated fatty acids, but slightly lower levels of monounsaturated fat and higher levels of omega-3 fat in organic meat. But the authors highlighted that the main differences were again likely related to grass-feeding, and that the reliability of the data in this study was found to be low.

Studies examining biomarkers or nutrient levels, eg, serum and urinary antioxidant levels, have not found any

Maeve Hanan UK Registered Dietitian Freelance Maeve is a Consultant Dietitian and Health Writer.

She 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

www.NHDmag.com December 2019 / January 2020 - Issue 150

41

FOOD & DRINK clinically significant differences when organic food was compared with conventional foods.7 It could be argued that the avoidance of genetically-modified (GM) technology in organic food production is limiting in terms of nutrition.

This is because GM technology can be used in very beneficial ways. The most famous example of this is production of ‘golden rice’, which is fortified with vitamin A in order to combat vitamin A deficiency (a leading cause of mortality and childhood blindness) in the developing world.11 Another exciting application is the creation of a plant-based source of haem iron using the roots of soya plants from US company Impossible Foods.

FOOD SAFETY

Pesticide residue has been found to exceed the maximum residue level (MRL) in both conventional and organic produce; however, this is more common in conventional produce.12 For example, organically grown fruit and nuts exceeded the MRL in 0.4% of cases, whereas this occurred in 2.7% of cases for conventionally grown versions.12 Similarly, organic vegetables exceeded the MRL in 0.5% of cases, whereas conventional vegetables exceeded this in 3.4% of the sample.12 But, it isn’t clear whether pesticide exposure has a direct impact on human health. A recent Danish study found that the effects of chronic pesticide residue consumption was insignificant to health.13 Specifically, chronic pesticide exposure was estimated to have the same health impact as consuming one glass of wine every seven years!13 A high exposure to pesticides in the womb, or in early life, may contribute to worsened cognitive development in children; but evidence is mixed about this.14 Other studies have found that organic vegetables tend to contain lower nitrate levels, although nitrate levels in conventional vegetables are still well below safety cutoffs.15 There is also uncertainty about whether consuming nitrates are harmful, as they have been linked with increasing cancer risk, but may also have heart health benefits, eg, reducing blood pressure.16,17 Organic fruit and vegetables may contain higher levels of natural toxins, but this is based on speculation rather than direct research.15 Organic production of animal-based products has also been associated with slightly higher contamination levels, but this remains within 42

food safety limits.15 Organic fruit and vegetables may have a slightly higher risk of E. coli contamination,7 but, overall, it seems that food safety is more highly influenced by other factors, rather than whether organic or conventional production methods have been used.15 OVERALL IMPACT ON HEALTH

There isn’t strong enough evidence to suggest that consuming organic food confers a significant health benefit.8 Some observational evidence exists around the consumption of organic food and the likelihood of consumers being within the healthy BMI range.14 But this link isn’t robust, as it is likely to have been confounded by the fact that those who consume organic food also tend to have other healthy habits.18 A systematic review from 2012 compared the safety of organic versus conventional food types.7 This identified no differences in terms of the risk of allergy or campylobacter infections between those who consumed organic or conventional food.

The lower use of antibiotics in the production of meat and dairy is an important advantage of organic production, due to the global issue of antibiotic resistance.14 However, this is less of a concern in Europe.5 It could also be argued that the environmental and social benefits related to organic production methods may have a positive impact on human health in a wider sense.

ORGANIC CONSUMERS

Some studies suggest that consumers who buy organic are more likely to be educated females in a higher income category.19,20 This may be related to the fact that organic produce can be 13% to 200% more expensive, often because of smallerscale production.21,22 It is commonly believed that organic food tastes better than conventional products. However, there is no strong evidence to back this up, as research in this area has been very mixed.23,24 CONCLUSION

Organic food isn’t necessary for good health.

There is much more evidence to support the benefits of a healthy balanced diet, which includes plenty of plant-based foods, regardless of whether these foods are organic or not.

www.NHDmag.com December 2019 / January 2020 - Issue 150

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F2F

FACE TO FACE Ursula meets: GREG LESSONS Nutritionist, London Fire Brigade (LFB) Associate Lecturer, London Metropolitan University 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.

44

Caroline Walker Trust: Nutritionist of the year, 2019

Greg is the one-and-only in many ways.

Not least his jump out of the fire into the frying pan. Meaning his career move from active duty as a firefighter, towards the food and wellness terrain of occupational nutritionist. Because he is bilingual (fire-talk and nutrition-talk).

And because he has opened so many doors, for future nutritionists to support occupational groups.

He was always going to be a firefighter. Not being 18, he passed the time and completed a BTEC National Diploma in Public Services, while also completing an A-level in Sociology at night school. A lecturer suggested that doing a degree would allow him better prospects. “My father thought this was a work-evasion tactic, but I was lucky: it was the last year of free higher education,” said Greg. He completed a three-year BSc in Exercise and Sports Sciences in 2000 at the University of Exeter.

Greg did a short stint as a personal trainer in a London City gym. It was great fun and a way to meet lots of interesting people, but perhaps a bit, in many ways, repetitive. So, Greg did what he had to do and joined the London Fire Brigade.

“You had to pass a difficult really intense 16-week training course,” explained Greg. Initially the course leader felt he was too cucumber-cool to join the team. But Greg passed the hoops and loops needed to be a firefighter and enjoyed many years of adrenalin and camaraderie.

www.NHDmag.com December 2019 / January 2020 - Issue 150

Ursula meets amazing people who influence nutrition policies and practices in the UK. He has always been interested in health and nutrition and, in 2014, he decided to do a part-time Masters in Human Nutrition (Public Health/ Sports) at London Metropolitan University. With the juggling of leave days and shift swaps with kind colleagues, Greg managed to continue his full-time post as a firefighter. “It was quite difficult to master complex texts after such a long time away from being a student. I had hoped to learn the hidden secrets of nutrition science, but was surprised that many issues were so debated and up to interpretation. I was very excited by many of the new themes in nutrition research, such as the influence of diet on the microbiome and chrono-nutrition.”

Greg was going to do his dissertation on the microbiome, but course leader Dee Bhakta had other ideas. She pointed to the obvious: his deep knowledge and affinity with the Fire Service made this the perfect theme for his dissertation and then found this to be unchartered territory for UK nutrition researchers.

So, Greg assessed the diets and health markers of eight watches (teams) of firefighters. They willingly had their body composition analysed and dietary behaviour assessed. Greg provided individual support and guidance on diet improvement to one group (vs a control group). “I was thrilled upon analysing the data,” said Greg, as his pilot trial showed improved dietary behaviour resulting in significant body fat reductions. He presented his project

F2F

Greg’s achievements are impressive.

And he has just clocked another: The Caroline Walker Trust Nutritionist of the Year (2019) award.

to a meeting of the Nutrition Society and won the prize for best delivery – resulting in his study being published in the journal Proceedings of the Nutrition Society. The well-deserved holiday after the course was all the better with the revelation that he had passed with distinction.

Aside from jokes and constant ribbing from colleagues about his food focus, several senior staff at the London Fire Brigade heard about the nutrition project. “I had just finished presenting my project to a Borough Commander, when the alarm bell rang. So, I ran into action with the parting words, ‘On that note, I’ve got to go’.”

In April 2018, Greg was offered a detachment from professional duty, to test whether an extension of his nutrition intervention could work on a sample of 300 firefighters over a longer intervention period… and it did. He now circuits several London boroughs, delivering nutrition and health education to watches, assessing their nutritional status and offering one-to-one advice, plus general support and encouragement towards better dietary and lifestyle choices. He is delighted with the Nutrition Society’s generous donation of a Tanita body composition analyser, and his previous reticence at public speaking and oral presentation is now long forgotten. Only a few months ago, he presented his updated project to the London Assembly at City Hall to great acclaim. “You should be incredibly proud of yourself,” was a comment made.

I wondered about diets of firefighters. Were they really so different from Mr/s Average

Londoner? Greg explained that firefighters are a close group who work together and eat together. The convivial mealtimes influence calorie intake and constant alertness leads to speed eating habits. Foods purchased are group choices and so have to be popular, easy and quick to prepare, as well as meet a tight budget.

In order to improve nutrition quality, Greg has to offer choices that are realistic and creative, providing small steps towards improvement.

“Many watches now use wholegrain cereals, opt for fruits over cakes and biscuits and increase oily fish choices,” said Greg. “The best way to find solutions, is to really listen to the problems.”

Greg is now signed up to doing a PhD, which he hopes to complete in 2021. In parallel with his official post as Nutritionist for the London Fire Brigade, he lectures part time on Sports Nutrition at the London Metropolitan University. “What keeps me going is the overwhelmingly positive feedback I receive from firefighters on a daily basis.”

Greg’s achievements are impressive. And he has just clocked another: The Caroline Walker Trust Nutritionist of the Year (2019) award. But behind him, I detect the constant support of his nutrition lecturer, Dr Dee Bhakta and also the really solid encouragement by his employer, the London Fire Brigade. Greg has bashed open doors, firefighter-style, to demonstrate the benefits of nutrition support to professional groups. Others need to follow.

www.NHDmag.com December 2019 / January 2020 - Issue 150

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A DAY IN THE LIFE OF . . .

A WORKPLACE NUTRITION DIETITIAN I have been a dietitian for over 10 years and have been lucky enough to work in many areas of dietetics, including gaining experience in gastroenterology and nutrition support in the acute setting with my first job. I was then lucky to obtain a job specialising in stroke rehab, an area I am passionate about and something that can be influenced by diet and lifestyle.

One of my other specialisms is in palliative care in the hospice setting. As per recent headlines, our diet and lifestyle can increase the risk of developing certain diseases and some cancers may be preventable by eating a healthier diet and getting enough exercise.1 This is one of the main reasons I have developed a passion for workplace health, as it’s where I feel there is a huge opportunity to achieve small changes, which can influence the occurrence of disease. Over the past year, I have developed my own company Care 4 Nutrition and I have recently gained accreditation from the BDA Work Ready Programme, which has helped me develop in this area.

I normally have two types of freelance day: home office and out of the office.

HOME OFFICE DAY

I rise at 7.30am and have a good breakfast to get my day off to a good start. As a workplace health dietitian, I know all too much about the importance of starting the day with a balanced breakfast containing some carbohydrate, protein and one of my five a day. Most days for me that’s porridge with milk topped with fresh fruit.

I then catch up with emails from clients. This could be around planning a session for a specific company, or getting more information for a workplace nutrition assessment. Preparation is key when planning any intervention,

as this can help tailor to the needs of the company. For example, I was recently asked to focus on food and mood due to management seeing an increase in absence as a result of mental health concerns. I may also spend time analysing results from assessments I have done, or work on a report.

I sometimes make time for a quick gym class, which can help me stay refreshed in my working day. Exercise is proven to help increase concentration levels and leave you feeling revitalised.

I definitely feel the benefits of doing this during the working day and when I am working in my other roles, I try to get out for a brisk walk at lunchtime (and encourage my colleagues to do the same). I have a quick shower and tuck into an easy lunch. Evidence suggests that those who skip lunch are more likely to be less productive in the working day.2 I love to have various salads, ensuring that there is also some protein like chicken breast and some carbohydrate such as wholegrain bread.

I then spend some time on social media, including Instagram, Twitter and LinkedIn. I find these are very useful for networking and marketing my services.

I will also check to see what has been in the media regarding food and nutrition and I may post on social media about anything relevant. I also make time to share content from fellow registered dietitians. It’s important to me that I am helping to share and spread evidencebased advice.

Elaine Anderson RD Workplace Health and Nutrition Dietitian Elaine is working as a part-time freelance dietitian. She is the founder of Care 4 Nutrition (www. care4nutrition. co.uk/), which specialises in workplace health.

This is alongside her NHS and charity roles.

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

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MATTHEW’S FRIENDS WILL BE HOSTING THEIR 5TH ANNUAL KETOCOLLEGE PROGRAMME

12TH - 14TH MAY 2020

CROWNE PLAZA FELBRIDGE HOTEL • EAST GRINSTEAD • WEST SUSSEX • UK AN ADVANCED CPD COURSE FOR NEW AND REFRESHER KETOGENIC DIETARY THERAPY LEARNING AND NETWORKING In its 5th year, KetoCollege 2020 offers both scientific background and practical training in all aspects of implementation of the different ketogenic therapies. Led by recognised ketogenic diet experts, it will include presentations, workshops and time for networking and group discussions. Registrations are welcome from allied medical health care professionals currently working with or looking to expand their knowledge of Ketogenic Dietary Therapies for epilepsy and other neurological disorders.

For the full programme and registration details, please visit www.mfclinics.com/keto-college or to register your interest please email: ketocollege@mfclinics.com BDA AND RCPCH CPD APPROVAL PENDING

7TH GLOBAL SYMPOSIUM ON MEDICAL KETOGENIC DIETARY THERAPIES

6TH-10TH OCTOBER 2020 B R I G H TO N H I LTO N M E T R O P O L E | U K

COLLABORATIVE SCIENCE AND CLINICAL CARE Opening of Online Abstract Submission 2nd March 2020

KEY DATES: Abstract Submission Deadline 26th June 2020

Early-bird Registration Closes 30th April 2020

register interest at: globalketo2020@matthewsfriends.org

#KETO2020 WWW.GLOBALKETO.COM

A DAY IN THE LIFE OF . . .

I have developed a passion for workplace health, as itâ&#x20AC;&#x2122;s where I feel there is a huge opportunity to achieve small changes, which can influence the occurrence of disease.

I will then spend more time planning sessions, ensuring I have researched the company I am working for and the types of employees they have. I normally prepare resources such as handouts or tailored information in advance. I always make some time at least once a week for continuing professional development, whether it be watching a webinar or reading a new journal around the evidence for workplace nutrition and health interventions.

OUT OF OFFICE DAY

My morning mainly consists of final preparation for a workshop I am running, or groundwork for one-to-one sessions with employees. This may be gathering resources such as dietary information sheets. I will also make sure my workshop is timed to perfection, as I donâ&#x20AC;&#x2122;t want to over run in a busy corporate environment. If I am running a food demonstration, I also prepare for this in the morning, so the food is fresh. The types of clients I see may be in healthcare, logistics, the beauty industry, construction or public relations, to name but a few.

I will then travel to provide the intervention and sometimes stay behind afterwards to provide information for staff if there are any particular questions. I will always take time to have some lunch if I am out for the day and ensure I drink

plenty of water. Dehydration has been found to have an impact on brain structures, similar to mild cognitive impairment.3 Another day may consist of touring a worksite from a small office to a large site, including identifying potential barriers to healthy eating.

This may also comprise of touring a catering facility, or chatting with staff on an individual level. I will meet with relevant individuals including, for example, the HR manager who will help with tailoring a nutritional needs assessment.

If there is any time at the end of the day, I will begin to evaluate my intervention, or start writing my report. Evaluation is key to any workplace nutrition intervention.4 This shows if something has worked, has been useful and can also show a return on investment. In the current economic climate, big budgets for workplace health are being slashed, so companies need to see that they are investing in something worthwhile.

I feel privileged to be able to share the knowledge of how diet and lifestyle choices can influence how we work, feel and behave, but, most importantly, how it impacts on our longterm health. I hope that working outside of the healthcare setting will help increase awareness of the importance of prevention, whilst helping companies develop a happier, healthier and more productive workforce.

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EVENTS & PUBLIC HEALTH COURSES THE ROYAL MARSDEN FOUNDATION TRUST - EVENTS AND STUDY DAYS 9th Mar 2020: Challenges of Non-Medical Prescribing in a Cancer Population EVENT ID 765 12th Mar 2020: Foundation in Oncology for Speech and Language Therapists EVENT ID 680 14th Mar 2020: Everything you ever wanted to know about: The Role of Radiology in Cancer Diagnosis and Treatment - EVENT ID 743 Costs: £120 per event. www.royalmarsden.nhs.uk/news-and-events/ conference-centre/study-days-and-conferences

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

MATTHEW’S FRIENDS – KETOCOLLEGE PROGRAMME Medical Ketogenic Dietary Therapy learning and networking 12th-14th May 2020 Crowne Plaza Felbridge, East Grinstead www.mfclinics.com/keto-college/ketocollege-uk-2020

BRITISH NUTRITION FOUNDATION (BNF) WEBINAR: Personalised Nutrition – Is it all in the gut?

18th Dec 2019 FREE lunchtime webinar 1-2pm www.nutrition.org.uk/component/rseventspro/ event/60-free-bnf-webinar-personalised-nutrition-isit-all-in-the-gut.html

SUGAR AWARENESS WEEK 20th-26th Jan 2020 #sugarawarenessweek Facebook: Action on Sugar Twitter @actiononsugar Instagram: actiononsaltandsugar www.actiononsugar.org/sugar-awareness-week/ sugar-awareness-week-2020/get-involve

DIETETIC SUPPORT WORKER AWARD ENHANCING COMMUNICATION SKILLS IN PRACTICE 7th Jan 2020 BDA Trainer: Dr Fiona McCullough London Road Community Hospital, Derby www.ncore.org.uk

AFN CPD TRAINING EVENTS www.associationfornutrition.org/Default. aspx?tabid=195 NUTRITION SOCIETY TRAINING ACADEMY EVENTS, WEBINARS AND WORKSHOPS www.nutritionsociety.org/events/training

dieteticJOBS.co.uk

01342 824073 FULL-TIME DIETITIAN – LONDON – LOUISE PARKER Louise Parker Ltd is seeking a friendly and professional Dietitian to join their vibrant team, providing an outstanding service to clients. The successful candidate will have a passion for health and wellbeing and will enjoy supporting clients as they change their lifestyles.

The successful candidate will be client-focused and passionate about providing evidence-based and compassionate nutrition and lifestyle advice to up to 40 clients at any point in time. You will support clients in making habitual changes in person, by email and

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remotely (eg, telephone, Skype, FaceTime) making outstanding communication and motivational skills essential to the role. You will also be expected to continuously improve and update our nutritional and behaviour-change Method as the world of nutritional science evolves. We are looking for a dynamic team player who is highly efficient and consistently produces a high standard of work. This is a full-time role based in Louise Parker’s Walton Street clinic, with a salary of £28,000 to £35,000 based on experience. Send a CV or any questions to: recruit@louiseparker.com.

www.NHDmag.com December 2019 / January 2020 - Issue 150

BACK TO THE FUTURE!

I can’t quite believe that this is the last issue of NHD for 2019. As the New Year approaches, it gives me time to reflect on the past Over the summer, celery juice was 12 months. hailed on social media as a magical As with recent years, 2019 has been full of cure for chronic illness (if only it was nutrition stories, some good, some bad, that easy!) and vegans were warned to but most exaggerated by the press. The make sure that they were eating enough year started with the annual Veganuary choline in their diet (BMJ Nutrition). with plenty of stories and tips on being August bought the long-awaited vegan. New year, new you and there Saturated Fat and Health report from the were also plenty of stories about sugar Scientific Advisory Committee on Nutrition and how to decrease it. Readers of this (SACN). There were no surprises though, column may remember that I contributed as it recommended to keep the amount of by talking about sugar on the local BBC saturated fat in our diet to no more than 10% of energy. This disappointed fans on news Midlands Today with Nick Owen.

February gave us some sense, with a the low carb high fat diet! team from Glasgow University looking September saw red meat back on the at the country’s most popular social menu with claims that the evidence that media influencers (based on those who red meat is linked to poor health is weak. had at least 80,000 followers on one site). The headlines implied we should eat lots They found that only one out of nine of meat, which is not the case. One of my leading UK bloggers making weight favourite web sites is NHS behind the management claims provided accurate headlines (www.nhs.uk/news). It always and trustworthy information. Eek! time throws some sense into the confusion to get on social media folks! and NHD tries to post up factual reports In May, ultra-processed foods were from this site whenever relevant. The linked to an early death! According to latest News pages (www.nhdmag.com/ the news reports, chicken nuggets, ice latest-news.html) are always a good cream and cereal are all going to kill us. starting point for our industry headlines.

Ok, slightly over the top. Just cut down on Moving into autumn, October them and have more vegetables and fruit! highlighted malnutrition in the com We then increased the positivity in June munity and hospitals, with the second for Dietitians Week. #whatdietitiansdo Malnutrition Awareness Week. was filling up our social media feeds, What a nutrition story filled year! Get with dietitians showcasing what they did ready for the whole cycle to start again best. The BDA ran a competition to find in 2020. Let’s be ready to combat the a photo that encapsulated the role of a misinformation out there by posting/ dietitian and I was involved in a charity blogging /tweeting credible nutritional recipe book, Dietitian Approved, that raised information. Here’s to a Happy and over £1000.

Healthy 2020.

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

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For healthcare professionals only

Are you considering the immune challenges surrounding infants with cow’s milk allergy?

A critical time of life Breast milk is the gold standard in the first year of life, providing not only nutrition, but protection and support for the developing immune system.1,2 Immunologically vulnerable Without the protective benefits of breast milk, formula-fed infants with cow’s milk allergy are at higher risk of several inflammatory and allergic conditions.1,3–6

A new infant formula Abbott will soon launch EleCare®, by Similac®, the first amino-acid based infant formula in the UK with 2’-FL HMO*, designed to support the infant’s developing immune system.

To find out more contact your Abbott Account Manager, or call our Freephone Nutrition Helpline on 0800 252 882

IMPORTANT NOTICE: Breastfeeding is best for infants and is recommended for as long as possible during infancy. *Not sourced from human milk.

2’-FL HMO: 2’-fucosyllactose human milk oligosaccharide. HMOs are a diverse group of bioactive, non-digestible carbohydrates and the third most abundant solid component of breast milk.7,8 References. 1. Kainonen E, et al. Br J Nutr. 2013;109(11):1962–1970. 2. Walker A. J Pediatr. 2010;156(Suppl 2):S3–S7. 3. Flom JD, Sicherer SH. Nutrients. 2019;11(5):E1051. 4. Oddy WH. Ann Nutr Metab. 2017;70(Suppl 2):26–36. 5. Lifschitz C, Szajewska H. Eur J Pediatr. 2015;174(2): 141–150. 6. Jo J, et al. Mediators Inflamm. 2014;2014:249784. 7. Triantis V, et al. Front Pediatr. 2018;6:190. 8. Castanys-Muñoz E, et al. Adv Nutr. 2016;7(2):323–330.

ANUKANI190277h November 2019