IG D AL IT LY
ON E SU IS
NHDmag.com
Issue 99 November 2014
preterm infant nutrition ISSN 1756-9567 (Online)
Too Lean a Service? . . . p25 Bariatric Surgery
Gail Pinnock Specialist Bariatric Surgery Dietitian
cereals, fibres & wholegrains cholesterol nutrition & cancer care gluten-free guide
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from the editor Welcome to the penultimate issue before NHD celebrates being 100 in December! This month offers another mixed selection of articles for you to feast your eyes on.
Chris Rudd NHD Editor Chris Rudd’s career in continuous dietetic service has spanned 35 years. She is now working part time with the Sheffield PCT Medicines Management Team, as a Dietetic Advisor.
@NHDmagazine
Carol Raaff has previously taken us through the rationale and design concept and then documented the development phases of a Child Weight Management app. Now Carol completes her trio of articles, Finalising an e-resource for clinical dietetic practice and shares with us how the app development comes to a close and offers a reflection on the process as a whole. Her experience resembled a roller coaster at times and she provides us with some tips and advice should you be thinking of developing an app. Just over two years ago, there was the NCEPOD report Too Lean a Service? Gail Pinnock was one of two dietitians involved in a team of healthcare professionals who were privileged to be involved in that process and from her article Too Lean a Service? Moving on from the NCEPOD report on Bariatric Surgery, it sounds like it was a great opportunity. Some of you may be aware of this report, but do you know what has happened since then? Gail, also a member of The British Obesity and Metabolic Surgery Society (BOMSS), informs us in her article of how bariatric surgery practice has progressed. Cancers of the head and neck are the sixth most common cancer worldEditor Chris Rudd RD Features Editor Ursula Arens RD Design Heather Dewhurst Sales Richard Mair richard@networkhealthgroup.co.uk Publisher Geoff Weate Publishing Assistant Lisa Jackson
wide and represent approximately 8,800 new cases and 2,700 deaths per year in England and Wales. At diagnosis, greater than 50 percent of head and neck cancer patients are malnourished. Nutrition support for head and neck oncology patients having radiotherapy by Jennifer Hoare tells us of the nutritional implications, the nutritional requirements and forms of nutritional support for this group of patients. Preterm infants are defined as being born before 37 weeks and their nutritional requirements are higher than for infants born at term. We offer you two articles on preterm infants. Improving outcomes by optimising nutrition for preterm infants by Kate Harrod-Wild, gives an overview on the topic. Establishing breastfeeding in a preterm baby by Shona Brennan covers a case study of baby D born at 34 weeks gestation and how early discharge home from the Neonatal Unit was achieved by nasogastric feeding before full breastfeeding was established. There are also articles on cereals by Carrie Ruxton and cholesterol by Ursula Arens and please take a look at the useful gluten-free guide. I hope you enjoy issue 99!
Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Fax 0870 762 3713 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk
All rights reserved. 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.
NHDmag.com November 2014 - Issue 99
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Contents
13
COVER STORY
Preterm infant nutrition 6
News
37 Gluten-free guide
8
Cereals, fibres and wholegrains
40 Book review
17 Preterm infant case study
42 Web watch
21 Cholesterol
44 Subscribe to NHD Magazine
25 Bariatric surgery
45 dieteticJOBS
29 Nutrition and cancer care
46 Events and courses
32 Child weight management
47 The final helping
Editorial Panel Chris Rudd Dietetic Advisor
Jacqui Lowden Paediatric Dietitian
Neil Donnelly Fellow of the BDA
Michèle J Sadler Director, Rank Nutrition Ltd
Ursula Arens Writer, Nutrition & Dietetics
Shona Brennan Specialist Neonatal Dietitian
Dr Carrie Ruxton Freelance Dietitian
Kate Harrod-Wild Specialist Paediatric Dietitian
Dr Emma Derbyshire Nutritionist, Health Writer
Gail Pinnock Specialist Bariatric Surgery Dietitian
Dr Anita MacDonald Consultant Dietitian in IMD
Jennifer Hoare Senior Macmillan Oncology Dietitian
Emma Coates Senior Paediatric Dietitian
Carol Raaff Paediatric Dietitian Child Weight Management
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NHDmag.com November 2014 - Issue 99
Packaging is changing! We are changing packs while expanding our Aptamil Pepti milks range.
From November 2014
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To order or prescribe please use the full name. Eg: Milupa Aptamil Pepti 1 800g (PIP code 391-8976) IMPORTANT NOTICE: Aptamil Pepti 1&2 are foods for special medical purposes. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth, and as part of a balanced diet from 6-12 months.
Please visit aptamilprofessional.co.uk if any further information is required.
Danone Early Life Nutrition. White Horse Business Park, Trowbridge, Wiltshire BA14 0XQ, United Kingdom.
news
industry / product news
NHD announces a new columnist for our news pages
Dr Carrie Ruxton is moving on from the News pages of NHD Magazine and we would like to pass on our sincere thanks to Carrie for writing the NHD news column for so many years.
Dr Emma Derbyshire Nutritionist and Health Writer
Carrie will continue to write articles for NHD and we wish her well in all her endeavours. You can link up with Carrie on twitter@drcarrieruxton and visit her website: www.nutrition-communications.com.
food matters live Major new event invites healthcare professionals to help shape future of UK food and drink The annual cost to the UK from poor diets is predicted to reach £27 billion by 2015 – with over 60% of adults overweight or obese, as well as a third of 10-11 year olds. Now, a major new free-to-attend event is bringing together experts in a range of fields to explore the vital role that the food and drink sector plays in the nation’s health. Taking place at London’s ExCeL from Tuesday 18 to Thursday 20 November, Food Matters Live is a unique cross-sector forum that’s set to attract some 10,000 visitors from the worlds of health, nutrition, research, food retail, manufacturing and government. The three-day event will host a carefully curated exhibition featuring 200 leading organisations, as well as providing an unrivalled education programme delivered by more than 450 speakers. Food Matters Live is free to attend – to register for your free ticket visit www. foodmatterslive.com 6
NHDmag.com November 2014 - Issue 99
We warmly welcome Dr Emma Derbyshire as our new News columnist from the next issue. Emma is founder of Nutritional Insight Ltd, Consultancy to industry. She is a nutritionist and awardwinning health writer. Emma can also be found on twitter@DrDerbyshire.
NEW Meritene® Energis® Taking a step forward in healthy ageing
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cereals
Contribution of breakfast cereals to fibre and wholegrains
Dr Carrie Ruxton PhD, RD Freelance Dietitian
Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods. www.nutritioncommunications.com
@drcarrieruxton
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Most dietary recommendations around the world include reference to dietary fibre and, sometimes, wholegrain foods. The European Food Safety Authority (EFSA) defines fibre as ‘all carbohydrate components occurring in foods that are not digested in the human intestine’, which includes nonstarch polysaccharides (NSP), resistant starch, resistant oligosaccharides and other non-digestible components, such as lignin. The recommendation is set at 25g/day for adults, while children from the age of one year should aim for 2.0g/MJ (1). In the US (2), men aged up to 50 years are advised to eat 38g fibre daily while women should eat 25g/day. Older adults have a reduced recommendation of 30g/day for men and 21g/day for women due to lower energy requirements. In the UK, a different approach was taken, in that dietary reference values (DRV) were couched as NSP (12-24g daily), rather than AOAC (Southgate) fibre which were used on EU food labelling and EU/US recommendations (3). This led to some confusion for consumers and health professionals. Thankfully, a recent review by the Scientific Advisory Committee on Nutrition (SACN) (4) has recommended changing the fibre definition to AOAC and increasing it to 30g/day for people aged 16 years and over, 15g for two- to five-year-olds and 20-25g for five to 16-year-olds. Wholegrain recommendations have been set by countries such as the US, Canada, Australia, Denmark and Sweden. The term ‘wholegrain’ typically refers to the edible grain of cereals which includes the entire bran, endosperm and germ (the hull and glume which are inedible are removed) (5). Adult recommendations range from three to eight servings daily in the US, to six to 12 servings daily in Australia and Denmark. The UK currently has no wholegrain recommendation, but this
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may change given that the SACN report (4) endorsed a dietary pattern ‘based on wholegrains, pulses, potatoes, vegetables and fruits’. UK intakes and sources
The most recent National Diet and Nutrition Survey (NDNS) estimated that average NSP fibre intakes are 14.7g in men and 12.8g in women (6), with children consuming 8.0-12g daily. Translated into AOAC fibre and compared with the new DRV proposed by SACN, it can be seen that there remains a large gap between current fibre intakes and what we should be consuming for health (see Figure 1). The median intake of wholegrains in the UK was estimated from two previous NDNS in adults and was reported to be less than one serving daily (7). This study also found that one third of adults did not consume any wholegrain foods, while over 97 percent failed to meet the US recommendation of three wholegrain servings daily. As wholegrain foods are known to correlate strongly with fibre consumption, it would be useful to offer advice to the public on sources of wholegrain foods in the diet. Cereals are one of the most important sources of fibre in the diet as well as being the only source of wholegrains. According to the most recent NDNS (6), foods, such as breakfast cereals, bread, pasta and rice, provided more than a third of NSP intakes in the UK diet, with another 20-33% coming from fruit
cereals Figure 1: The gap between fibre intakes and recommendations
Key: DRV, dietary reference value. Source: National Diet & Nutrition Survey (6).
and vegetables (Figure 2). As may be expected, the contribution of fruit and vegetables to fibre intake was lowest in teenagers, while the con-
tribution of potatoes and chips was greatest, reflecting their different eating habits. High fibre varieties of breakfast cereals made a signifi-
Figure 2: Contribution of key food groups to fibre intakes
Key: y, year. Source: National Diet & Nutrition Survey (6) NHDmag.com November 2014 - Issue 99
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cereals Table 1: Evidence-based benefits for fibre and wholegrains Fibre
Wholegrains
Cereal fibre
High fibre breakfast cereals
Lower risk of CVD or coronary events
3
3
3
3
Lower risk of stroke
3
3
N/A
N/A
Lower fasting blood lipids
X
X
3a
N/A
Lower blood pressure or reduced risk of hypertension
N/A
3
3a
N/A
Weight loss
X
N/A
N/A
N/A
Lower energy intakes
X
3
X
X
Lower risk of Type 2 diabetes
3
3
3
3
Increased intestinal transit time
3
N/A
3b
N/A
X
N/A
N/A
Lower risk of CRC
3
Key: Tick indicates acceptable evidence for an association and a plausible mechanism; N/A, no evidence presented; CRC, colorectal cancer; a evidence applies to oat fibre/beta glucans only; b evidence applies to wheat fibre only.
cant contribution to fibre intakes in pre-school children (10 percent) and in older adults (eight percent), reflecting their greater use in these age categories. Biscuits, cakes and pies provided six to eight percent of fibre intakes, but their high fat and sugar content would make them less suitable choices for boosting fibre. Key wholegrain sources in the diet include wholegrain breakfast cereals, wholemeal wheat, rye or oat bread, pittas made with wholemeal flour, wholegrain rice and wholewheat pasta. Greater choice of products, especially for breakfast cereals where the use of wholegrain or wheat fibre signposting has become more common, can help people to choose the most appropriate foods. It is also worth noting that ready-to-eat breakfast cereals are typically fortified with vitamins and minerals, thus increasing their contribution to the diet (8).
on 74 prospective cohort studies and 131 randomised controlled trials. The evidence is summarised in Table 1 below. Therefore, it can be seen that eating more fibre relates to a lower risk of heart disease, stroke, Type 2 diabetes and colorectal cancer. Fibre also boosts intestinal transit time, thus helping to prevent constipation. Wholegrains offer similar health benefits, but also help to lower the risk of hypertension and reduce short-term energy intakes, possibly due to an impact on satiety. The benefits associated with cereal fibre are dominated by studies on oat and wheat fibre, particularly oat beta glucans which have specific proven cholesterol-lowering effects. Interestingly, the evidence was sufficient to link increased intake of high fibre breakfast cereals with a lower risk of heart disease and Type 2 diabetes.
Potential health benefits
Advising patients
The health benefits of consuming fibre and wholegrains were reviewed by SACN (4) based 10
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Surveys on consumer attitudes to food labelling indicate that energy, fat and sugar remain the
Resources which identify and promote wholegrain options, or show visual portions of high fibre foods, are likely to be better understood by patients than fibre targets in grams. dietary components most understood and checked during shopping trips. Consumer knowledge of fibre benefits and sources is low, but there is an increased awareness of gut health, thanks to the expansion of choice in probiotic products. A new law brought in to standardise information on labels - the Food Information Regulation 2013 (9) - may have the unintended consequence of making consumers even less aware of fibre as it has removed ‘fibre’ from the mandatory nutrition declaration. This means that manufacturers do not need to display the fibre content of foods unless they are making ‘source of fibre’ or ‘high in fibre’ claims. The potential reduction in fibre signposting on labels, the lack of a specific wholegrain recommendation and a higher fibre DRV, all point towards the risk that the UK population will move further away from achieving optimal intakes of fibre. This means that health professionals, especially dietitians and nutritionists, will play a greater role in promoting fibre, highlighting the benefits, giving guidance on
key sources and portion sizes and interpreting the DRVs for different population groups. Advice to consider giving to patients would include translating age-related DRVs into foods and discussing the likely benefits for individuals (for example, prevention of constipation for young children and elderly, or weight management for overweight patients). Key fibre sources can then be explored, such as high fibre and wholegrain breakfast cereals, wholegrain pasta, rice and bread. Resources which identify and promote wholegrain options, or show visual portions of high fibre foods, are likely to be better understood by patients than fibre targets in grams. Acknowledgement
This article was funded by the Breakfast Cereal Information Service, an independent information body set up to provide balanced information on breakfast cereals. It is supported by a restricted educational grant from the Association of Cereal Food Manufacturers. See www.breakfastcereal. org for more information.
references 1 european Food Safety authority (2010). Scientific opinion on dietary reference values for carbohydrates and dietary fibre. eFSa Journal 83: 1462 2 US Department of agriculture (2013). Food Guide Pyramid. www.cnpp.usda.gov/FGP.htm 3 Department of Health (1991). Dietary reference Values for food energy and nutrients for the United Kingdom, 2nd edition, no. 41. London: tSO 4 Scientific advisory committee on Nutrition (2014). Draft carbohydrates and health report. London: SacN 5 5american association of cereal chemists International (1999). wholegrain task force, 1999: Definition of wholegrain. www.aaccnet.org/initiatives/definitions/ Pages/WholeGrain.aspx 6 Bates B et al. (2014). National Diet and Nutrition Survey. Rolling programme years 1-4. London: Food Standards Agency/Public Health England 7 7 Lang R et al. (2003). Consumption of wholegrain foods by British adults: findings from further analysis of two national dietary surveys. Public Health Nutr 6: 479-84 8 ruxton c (2014). Breakfast skipping and implications for diet and health. Network Health Dietitian 96 (July): 30-33 9 DeFra (2012). Food Information regulation: Guide to compliance. www.gov.uk/government/uploads/system/uploads/attachment_data/file/82663/consultfic-guidance-20121116.pdf
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THE MOST COMPLETE PRETERM RANGE At Cow & Gate, we have given our all in the development of the most comprehensive range available for preterm babies. By working closely with neonatal practitioners, Nutriprem is now the only preterm range that complies with the latest ESPGHAN guidance and includes a hydrolysed protein formula.1
For more information about preterm nutrition visit: www.in-practice.co.uk
Important notice Breastfeeding is best for babies. Cow & Gate Nutriprem 1 and Nutriprem 2 are foods for special medical purposes and should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. They are suitable for use as the sole source of nutrition for preterm and low birthweight infants. These products are for enteral use only. Infant formula is intended to replace breastmilk when mothers do not breastfeed. Infant formula should only be used on the advice of independent persons qualified in medicine, nutrition or pharmacy, or other professionals responsible for maternal and child care. Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50: 85–91.
cover story
Improving outcomes by optimising nutrition for preterm infants Preterm infants are defined as being born before 37 weeks (term). The smaller and more preterm the infant, the more vulnerable they are nutritionally, as they have not had the opportunity to develop nutritional reserves, as this would usually mostly occur during the third trimester of pregnancy. Therefore, provision of optimal nutrition must be a high priority on the neonatal unit. Specialist Paediatric Dietitian, Betsi Cadwaladr University Health Board
Kate Harrod-Wild is a paediatric dietitian with over 20 years’ experience of working with children in acute and community settings. Kate has also written and spoken extensively on child nutrition.
The nutritional requirements of preterm infants are higher than for infants born at term and the reasons are multifactorial: • Low nutritional reserves/stores • Immature organ systems - leading to increased work of breathing and reduced digestion and absorption of nutrients, for instance • Increased risk of infection (due to immature immune system) Care on the neonatal unit is designed to minimise the impact of these deficits; for instance, ventilation supports immature lungs where necessary and babies are nursed in incubators or hot cots to minimise the heat loss from immature skin. Comparison of nutritional requirements can be found in Table 1, from which it can be seen that nutritional requirements are significantly higher in preterm infants relative to size, with additional difficulties in meeting these requirements. Embleton et al (4) established that preterm infants accrue an inevitable protein deficit that is strongly correlated with postnatal growth retardation on the neonatal unit. Growth velocity in preterm neonates has been related to risk of cerebral palsy, subnormal mental development index and neurodevelopmental impairment (5). Neurological examination performed at 5.4 years by a neurologist blinded to perinatal outcome, found cognitive deficits were associated with intrauterine growth retardation (measured as weight at birth), poor neonatal weight gain and lower
post-discharge head circumference. Improved protein and energy intakes in just the first week were associated with improved neurodevelopmental scores at 18 months (6). Time taken to stabilise respiratory status, delays in starting and increasing parenteral and enteral feeds and episodes of sepsis leading to feeds being stopped, all contribute to deficits in nutritional status for preterm babies while on neonatal units. There has been an increased emphasis on standardised feeding regimes in neonatal units. Although there is still much research needed on optimal feeding regimes, standardised feeding regimes have been found to reduce rates of necrotising enterocolitis (NEC), a potentially devastating complication of prematurity which can lead to gut necrosis, gut resections and even death. Where standardised feeding regimes have been introduced, NEC rates have reduced and NEC has been virtually eliminated in some centres (7). As a result, neonatal networks have worked to develop enteral feeding guidelines to use across their networks, the most well-known of which is the East of England Network guideline. The Welsh Neonatal Network has been working on an enteral feeding guideline for our preterm infants, which is based on the East of England guideline (8). This launches in October 2014 at the Wales Neonatal Network Audit Day. An important principle once such a guideline is introduced is that a continuing cycle of process planning, consistent implementaNHDmag.com November 2014 - Issue 99
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preterm infant nutrition tion, review and audit of practice is prioritised and implemented (9). Most infants under <1,500g will not tolerate full nutritional requirements enterally from Day 1 and will need parenteral nutrition; this too will take several days to meet the infant’s full nutritional requirements. The immaturity of the preterm gut means that enteral feeds need to be advanced cautiously. However, it is important that enteral feeds are introduced as early as possible to prevent gut atrophy, leading to an increased risk of infection via the gut. However, advancing enteral feeds too fast risks NEC. Therefore, trophic feeding (up to 24mls/kg/d) is increasingly standard practice on neonatal units; giving small amounts of feed enterally to keep the gut patent while building up parenteral feeds, until the infant is stable enough to increase enteral feeds. A recent large prospective study (10) found that early introduction of enteral feeds in growth-restricted preterm infants, results in earlier achievement of full enteral feeding and does not appear to increase the risk of NEC. However, concerns regarding the risk of NEC mean that any change in practice around early feeding is likely to be viewed very conservatively. A new large multi-centred trial in the UK and Ireland undertaken by SIFT group (Speed Increasing Feeds Trial), aims to recruit 2,500 very preterm or VLBW infants to compare advancement of feeds at either 30ml/kg/day or 18ml/kg/day. This trial will recruit infants who are fed either human or formula milk. Initial results are awaited. Prospective, longitudinal nutritional studies in preterm infants started in the 1980s (11), evaluating the influence of early dietary practices on clinical and neurodevelopmental outcomes. Infants were randomised to receive either donor breast milk (DBM) or a preterm formula; either as whole diet or supplementary to mother’s breast milk. Only the infants fed preterm formula maintained their birth centile by discharge and at nine months corrected age, the mean developmental quotient was 0.25 standard deviation scores (SDS) lower for infants fed DBM compared with preterm formula (12). However, by 18 months corrected age (13), no differences were seen in developmental indices between the groups. It was concluded that, despite the relatively low 14
NHDmag.com November 2014 - Issue 99
nutrient content of breast milk - and particularly DBM (<50kcals/100mls vs 68kcals/100mls for term formula and 80kcals/100mls for preterm formula (14)) - it contained factors to promote neurodevelopment and offset any detrimental effects of poor nutrition. The advantage of breast milk was still seen at seven and a half to eight years, with children fed breast milk having a significantly higher Intelligence Quotient (IQ), which remained even after adjustment for mother’s education and social class. A dose response was seen between amount of milk consumed and subsequent IQ (15). Therefore, mothers’ own breast milk is the feed of choice on the neonatal unit for the reasons explained above. Use of breast milk is also well recognised to decrease the risk of NEC. In early studies, any breast milk (MEBM or donor breast milk DBM) was shown to reduce the incidence of NEC by up to tenfold (16). The protective effects of breast milk have been correlated with its anti-inflammatory components (IL-10), growth factors (EGF), erythropoietin, lysozymes and immunoglobulins as well as pre and probiotics which favourably affect gut microflora (17). Mothers should be given all necessary support to start expressing breast milk within a few hours after birth and encouraged to express at least eight times a day including at night. Techniques such as ‘hands on’ pump expression can help to maximise volumes and suitably trained midwives and neonatal nurses should provide ongoing support to ensure volumes are maintained and breasts are emptied to ensure the calorie rich hind milk is expressed. Breast milk from the mothers of preterm infants is known to be higher in protein than the milk of term infants, helping to provide the necessary extra protein intake (Table 2); although, after the first few weeks, protein levels start to fall towards term levels. Where MEBM is not available, donor breast milk is thought to be helpful in reducing the risk of NEC in high risk infants (<28 weeks; <1,000g; IUGR). However, this milk is often drip milk - so called because it drips from one breast while the baby feeds from the other. As a result, donor breast milk can be much lower in calories and protein than standard breast milk, which has adverse consequences for growth. More recently, preterm donor milk has become available from
Preterm infant nutrition Table 1: Nutritional requirements of preterm infants vs term infants Nutrient
Term infant (1)
Preterm infant Koletzko 2014 (2)
Preterm infant 1000gâ&#x20AC;&#x201C;1800g ESPGHAN 2010 (3)
Energy (kcal/kg/day)
95-115
110-130
110-135
2.0
3.5-4.5
4.0-4.5 (<1,000g) 3.5-4.0 (1,000-1,800g)
Sodium (mmol/kg/day)
1.5
3.0-5.0
3.0-5.0
Potassium (mmol/kg/day)
3.4
1.9-5.0
2.0â&#x20AC;&#x201C;3.5
Calcium (mmol/kg/day)
3.8
3.0-5.0
3.0-3.5
Phosphate (mmol/kg/day)
2.1
1.9-4.5
1.9-2.9
Protein (g/kg/day)
Table 2: Nutritional content of milks and fortifiers Energy (kcals/100mls)
Protein (g/100mls)
Preterm breast milk
70
1.8
Term breast milk
69
1.3
Term breast milk + BMF
84
2.1 -2.3
C&G Nutriprem 1
80
2.5
SMA Gold Prem
82
2.2
Aptamil Preterm
80
2.5
some milk banks, which should be used whenever possible. In addition, some breast milk banks are making nutritional analyses of their donor milk available, which makes it easier to assess the nutritional adequacy of the milk that is being provided. As a result of the desire to use breast milk to minimise the risk of NEC and also maximise cognitive outcome, breast milk fortifiers (BMF) have been developed, which add calories, protein and vitamins to breast milk, while enabling the full volume of breast milk to be given (see Table 2). Cochrane (18) found evidence of improved short-term weight gain, linear growth and head growth with the use of BMF and no evidence of increased risk of NEC. Nevertheless, care should be taken with addition of breast milk fortifier to minimise any risk of NEC. BLISS recommends that breast milk fortifier is used in infants <1,500g at birth and <34 weeks once they
are on full feeds and serum urea is <4.0mmols/l and falling (19). This is because there is a correlation between serum urea and protein content of milk (20). Where mothers do not wish to, or canâ&#x20AC;&#x2122;t provide breast milk, or produce insufficient volumes, preterm formulas are used, which are formulated to meet the high nutritional requirements of preterm infants (Table 2). Enteral feeding will usually be established using orogastric or nasogastric tubes. Oral feeding starts to develop from 32 weeks, however because of immature suck-swallow-breathe, most infants will not be able to breast or bottle feed totally until somewhere between 35 and 40 weeks gestation. Some units will send infants home while still tube fed, or on oxygen or both; policies differ locally depending on the services and support available to families in the community. Adequate nutritional intake should be assessed as part of thorough discharge planning. For a baby who has been on breast milk fortifier and is moving on to breastfeeding, they need to be able to take enough milk from the breast to support growth. Since breast milk fortifier is not prescribable in the community, there are limited options available if the infant does not thrive. Some units will supply breast milk fortifier for parents to mix with some expressed breast milk; alternatively, families may be advised to add formula powder to breast milk or give top-up feeds of post discharge or nutrient dense formula. For infants who have been on preterm formula on the unit, they will typically be discharged on a nutrient enriched post discharge formula (NEPDF), which is typically half way in NHDmag.com November 2014 - Issue 99
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Preterm infant nutrition
Dietitians are not currently universally members of the neonatal team; as the key role of nutrition becomes more recognised it is to be hoped that will change in the years to come.
composition between a preterm and standard formula (~75kcals/100mls; 2.0g protein/100mls). These also contain higher concentrations of vitamins and minerals to meet the ex-preterm infantâ&#x20AC;&#x2122;s continuing higher requirements. If an infant is breast milk fed or has a standard term formula they will need additional vitamin and iron supplements. If an infant is unable to take sufficient volume of breast milk or a NEPDF to gain weight satisfactorily, a term nutrient dense formula may be used (90 - 100kcals/100mls; 2.0 - 2.6g protein/100mls). These are not entirely suitable for preterm infants, but may be useful where infants are struggling to manage volumes, in con-
junction with vitamin and iron supplements. Preterm infants are born at a nutritional disadvantage and the current evidence suggests that current neonatal care is not successful in helping them to overcome those early disadvantages. However, much work is going on to improve this situation in the future. Dietitians are not currently universally members of the neonatal team; as the key role of nutrition becomes more recognised it is to be hoped that will change in the years to come. In the meantime, robust, standardised evidence based enteral feeding guidelines will help to ensure that preterm infants receive the best possible nutrition from their first day of postnatal life.
References 1 DH (1991). Dietary Reference Values: Report on Health and Social Subject No.41. London: HMSO 2 Koletzko B et al Eds (2014). Nutritional Care of Preterm Infants: Scientific Basis and Practical Guidelines. World Rev Nutr Diet. Basel, Karger. 110, 297-299 (DOI; 10. 1159/000360195) 3 Agostoni C et al (2010). Enteral Nutrient Supply for Preterm Infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. JPGN 50: 85-9 4 Embleton NE, Pang N, Cooke RJ (2001). Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? Pediatrics 107, 270-73 5 Ehrenkranz RA, Dusick AM, Vohr BR et al (2006). Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants. Pediatrics (online) 117, 1253-61 6 Stephens BE, Walden RV, Gargus RA et al (2009). First week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants. Pediatrics (online) 123, 1337-43 7 Patole SK and de Klerk N (2005). Impact of standardised feeding regimens on incidence of neonatal necrotising enterocolitis: a systematic review and meta-analysis of observational studies. arch Dis child Fetal Neonatal ed, 90, ppF147-151 8 east of england Neonatal Network (2012). enteral feeding on the neonatal unit. www.networks.nhs.uk/nhs-networks/southern-west-midlandsnewborn-network/guidelines-1/copy_of_guidelines/feeding-and-nutrition/attachment%2010%20SwMNN%20enteral%20feeding%20jan%20 2012.pdf/view?searchterm=enteral%20feeding%20neonatal 9 Horbar JD et al (2003). NIC/Q (2000). Establishing habits for improvement in neonatal intensive care units. Pediatrics, 111, pp397-410 10 Leaf A et al (2012). Early or delayed enteral feeding for preterm growth-restricted infants: a randomised trial. Pediatrics. 2012 May;129(5) :e1260-8 11 Lucas A, Gore SM, Cole TJ et al (1984). Multicentre trial on feeding low birthweight infants: effect of diet on early growth. Arch Dis Child (online) 59, 722-30 12 Lucas A, Morley R Cole, TG et al (1989). Early diet in preterm babies and developmental status in infancy. Arch Dis Child (online) 64, 1570-78 13 Lucas A, Morley R, Cole TJ et al (1990). Early diet in preterm babies and developmental status at 18 months. Lancet (online) 335, 1477-81 14 Lucas A, Morley R, Cole TJ et al (1994a). A randomised multicentre study of human milk versus formula and later development in preterm infants. Arch Dis Child Fetal Neonatal Ed (online) 70, F141-F146 15 Lucas A, Morley R (1992). Breast milk and subsequent intelligence quotient in children born preterm. Lancet (online) 339, 261-4 16 Lucas A, Cole T (1991). Breast milk and necrotising enterocolitis. Lancet 336, 1519-1523 17 Schnabl KL, Van Aerde, JE, Thomas ABR, Clandinin MT (2008). Necrotising enterocolitis; a multifactorial disease with no cure. World J Gastroenterology (online) 14, 2142-2161 18 Kuschel CA, Harding JE (2004). Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane Database of Systematic reviews, Issue 1. art. No. cD000343. available from http://dx.doi.org/ 10.1002/14651858.cD000343.pub 19 King c and Bell S (2010). Discussion paper on the use of breast milk fortifiers in the feeding of preterm infants. Bliss Briefings. BLISS www.bliss. org.uk/wpcontent/uploads/2012/07/bliss_briefings_webV2.pdf 20 Polberger SK, axelsson Ie, räihä Nc (1990). Urinary and serum urea as indicators of protein metabolism in very low birthweight infants fed varying human milk protein intakes. Acta Paediatr Scan 79, 737-42
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preterm infant feeding: case study
Establishing breastfeeding in a preterm baby Case Study: Early discharge home from the Neonatal Unit (NNU)
Shona Brennan Specialist Neonatal Dietitian, Sheffield Teaching Hospitals NHS Foundation Trust
Shona’s post as Specialist Neonatal Dietitian includes being part of the multidisciplinary and developmental care teams. Her particular interest is in supporting mothers in establishing lactation, breastfeeding and weaning. Shona is a member of the Paediatric Group of the BDA and Neonatal Dietitians’ Interest Group.
On our NNU, parents are actively encouraged to become involved in feeding their baby as soon as they feel ready and, for many, this will involve learning how to tube feed. Some preterm babies remain on the NNU solely because they are unable to take all of their feeds orally and need nasogastric feeds to supplement their nutritional requirements until they are mature enough to do so. For some babies and families this may take many weeks. Early discharge home of stable preterm infants still requiring some nasogastric feeds has the benefit of uniting families sooner and allows a more consistent approach to feeding by parents. Reducing the length of stay in hospital for preterm infants has been suggested to have emotional and psychological benefits for the family and for the infant’s development (1). Home tube feeding programmes have also been associated with successful weight gain and infants have not required readmission related to tube feeding (2, 3, 4). To ensure successful home tube feeding, parents need to be competent, confident, committed and well supported by community health professionals experienced in this area. On our NNU, any baby fulfilling the criteria in the Early Discharge guideline will be considered (5). Tube feeding at home could be an increased burden for some families and there is the possibility of complications relating to the tube feeding. Some parents choose not to take their baby home partially tube fed, preferring them to remain on the NNU until oral feeding is fully established. In our experience, however, most parents do choose to take their baby home early to continue to establish oral feeds (6).
This is a case report of a preterm infant who was discharged home early to continue to establish breastfeeding. Case study Baby D was born at 34 weeks gestation weighing 1.628kg (2nd to 9th centile). He was born by elective caesarean section for intrauterine growth retardation and placental insufficiency. He did not require any resuscitation at birth and was transferred to the NNU to start intravenous fluids. On the NNU, our aim is to support mothers to express their milk within two hours of birth. Midwifery staff explained the benefits of breast milk to Baby D’s mother, to encourage her to express her milk and she was shown how to hand express as it was her intention to breastfeed. By day six of life, Baby D had established full feeds via nasogastric tube using his mothers’ breast milk and he tolerated this well. Vitamin and iron supplements were started. As well as tube feeds, baby D was beginning to try and feed from the breast. His mother had been expressing regularly and had established a good milk supply, sufficient to support exclusive breastfeeding. Baby D was then transferred to Transitional Care. Transitional Care is part of the unit that enables mothers to stay with their babies and, with the support from neonatal staff, learn how to feed and care for their baby. This would include continuing to learn to tube feed and pass a nasogastric tube if early discharge was being considered. Baby D was discussed as part of the weekly Multidisciplinary Team (MDT) NHDmag.com November 2014 - Issue 99
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preterm infant feeding: case sutdy sleepy but did have periods when he was awake and alert. He was still having full nasogastric tube feeds. He was nine days old. His weight was 1.55kg. To help the transition from tube feeding to breastfeeding, a ‘Top Up’ plan is used. This helps to assess whether a tube top up is needed. The Top Up plan is based on the quality, as well as the time of breastfeeds and it also helps to continue to support growth during the transition process. Baby D was 13 days old the next time he was seen with his mother and was observed feeding at the breast. His mother was using a nipple shield which helped baby D achieve and maintain an effective latch at the breast. He demonstrated competent feeding skills, limBy ceejayoz (www.flickr.com/photos/ceejayoz/3579010939/) (GFDL (www.gnu.org/copyleft/ ited only by his energy reserve. At this fdl.html) or CC-BY-2.0 (creativecommons.org/licenses/by/2.0)), via Wikimedia Commons stage he was feeding from the breast four times with top ups and four of his ward round. He was seven days old. Early dis- feeds were full tube feeds in a 24-hour period. His charge had been mentioned to baby D’s mother and weight was 1.64kg (0.4th to 2nd centile) having this was something she was keen to do. She was regained his birth weight. The following evening, already doing all his cares and feeds and she was Baby D was discharged home at 36 weeks corvery eager for him to start breastfeeding. Until this rected gestational age on day 14 of life. point, baby D’s feeding attempts were mostly non- Community follow-up was arranged two days nutritive with no or minimal milk transfer. Early after discharge and he was reported to be feeding Discharge requires the baby to be making progress well with a similar pattern to that on the NNU, and with oral feeding as assessed by the MDT. he gained a further 40g. At the next home visit four Preterm infants are born before their feeding days later, his weight had increased to 1.80kg. He development is complete, so parents need to be continued to feed well, waking every three to three given realistic expectations at each stage of their and a half hours. His mother was still using a nipple baby’s feeding journey. Co-ordination develops shield. A week later he was fully demand breastwith increasing gestational age and is thought not feeding and his weight was 1.940kg. Community to be fully established before 35 to 37 weeks gesta- follow-up continued for a further two weeks; Baby tion. However, there is ongoing debate as to how D’s weight at the final visit was 2.370kg and he much is determined by gestational maturation continued to demand to breastfeed. and how much by experience (7, 8). Baby D was This case illustrates the benefits and success asleep the first time he was seen with his mother of early discharge home for Baby D, his parents on Transitional Care. She said that he was still very and the NNU. References 1 Casiro et al. Earlier discharge with community-based intervention for low birth weight infants: A randomised trial. Pediatrics 1993; 92: 128-34 2 Wakefield J, Ford L. Nasogastric tube feeding and early discharge. Paediatric Nursing 1994; 6: 18-19 3 Evanochko et al. Facilitating early discharge from the NICU: the development of a home gavage program and neonatal outpatient clinic. Neonatal Network 1996; 15:44 4 Swanson SC, Naber MM. Neonatal integrated home care: nursing without walls. Neonatal Network 1997; 16:33-8 5 Gastric tube feeding - early discharge (neonatal) Jessop Wing Unit guideline 2012. Jane Shaw Speech and Language Therapist 6 Bathie J, Shaw J. Early discharge home from the neonatal unit with the support of nasogastric tube feeding. Journal of Neonatal Nursing 2013; 19: 213-216 7 Gryboski JD. Suck and swallow in the premature infant. Pediatrics 1969; 43:96-102 8 Casaer P, Daniels H, Devlieger H et al. Feeding behaviour in preterm neonates. Early Hum Dev 1982; 7:331-346
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One bottle daily lowers LDL by up to 10% in just 3 weeks*
Benecol ® truly offers food for thought. Thanks to the action of its constituent Plant Stanol Ester (confirmed by a rigorous 30-trial review by the European Food Safety Authority), just one little bottle of Benecol® yogurt drink daily can actually reduce LDL cholesterol by 7–10% in just 3 weeks.1–3 And because its mode of action is complimentary, Benecol ® can even provide a further 10% reduction in LDL when used in conjunction with statins.4,5 References: 1. The EFSA Journal 2008; 825: 1–13. 2. Data on File. Johnson & Johnson Ltd. 3. European Commission 384, 2010. 4. Blair et al. Am J of Cardiol 2000; 86: 46–52. 5. De Jong et al. Brit J of Nutrition. 2008; 100: 937–941. *A daily intake of 1.5–3.0g plant stanols is proven to lower cholesterol by 7–10% in 2–3 weeks and each bottle contains 2g.
Proven to lower cholesterol
Cholesterol: saturated fats
Big fat fights This year, the gloves have come off in the arena of disputes within lipid metabolism. No longer just slight hints of distain and micro-correction among genteel academics at learned conferences, the battles now rage in shouty blogs, press headlines and anecdote-filled books. Ursula Arens Writer; Nutrition & Dietetics
Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula helps guide the NHD features agenda as well as contributing features and reviews
The new message, the one that is very much counter to current nutrition policy and firm dietetic advice and now cast-in-concrete food labelling laws, is that saturated fat is not bad at all; cream is not ‘naughty but nice’ - it is just nice. Should dietitians shift the long-steady rudder of dietary advice on saturates in relation to blood cholesterol levels and heart disease risk? A year ago (October 2013), an opinion piece written by cardiologist Dr Aseem Malhotra, was published in The British Medical Journal. The article: ‘From the Heart: saturated fat is not the major issue - let’s bust the myth of its role in heart disease’, was very widely discussed in media. Then, in March 2014, a bombshell paper was published in the Annals of Internal Medicine. Lead author Rajiv Chowdhury is a cardiovascular epidemiologist at the University of Cambridge, and major funding for the study came from the British Heart Foundation and the Medical Research Council. Impeccable expertise went into the study; explosive results came out. Chowdhury and colleagues did a systematic review and meta-analysis of published studies reporting dietary, circulating or supplement-source fatty acids and the risk of coronary disease. There were 32 studies with data on fatty acids from dietary intakes (from more than 510,000 participants), 17 studies with data of fatty acid biomarkers (from more than 25,000 participants) and 27 randomised controlled trials with data on fatty acid supplementation (from more than 105,000 participants). Coronary outcomes in pro-
spective cohort studies of dietary intakes showed a significant 16 percent increase in risk in people who consumed the top third of intakes of trans fatty acids compared to those with the bottom third of intakes. So there is clarity: higher intakes of dietary source trans fats increase the risk of coronary outcomes. However, the other observations were less consistent with expectations. The top versus bottom tertiles of saturated fatty acid intakes showed a small three percent increase in risk, and only very small reductions in risk of one percent and two percent could be observed for intakes of alpha linolenic and total n-6 fatty acids. Long chain n-3 fatty acids were protective (a 13 percent risk reduction in top tertile intakes), so fish eating remains a good idea. In contrast, variations in intakes of monounsaturated fatty acids showed zero effects on coronary events, so should olive oil messaging be muted? Looking at perhaps more accurate data from circulating fatty acids (in contrast to perhaps fuzzy food diary descriptions), another picture emerged. While total saturated fatty acids increased the risk of coronary outcomes by six percent, further breakdown by individual fatty acids showed the extremes of a 23 percent increase with stearic fatty acid (18:0), in contrast to a 33 percent reduction with margaric fatty acid (17:0). Trans fats appear minimally bad (five percent increase), total monounsaturated fatty acids appear even worse (six percent increase), while total n-3 and n-6 appear mildly protective, with reductions of seven percent and six NHDmag.com November 2014 - Issue 99
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Cholesterol: saturated fats
Should dietitians shift the long-steady rudder of dietary advice on saturates in relation to blood cholesterol levels and heart disease risk?
percent in the risk of a coronary outcome. What about fatty acid supplements in relation to the risk of a coronary event? Perhaps obviously, there are no studies where participants are asked to take supplements with saturated fatty acids. Studies of alpha-linolenic acid supplements (n-3) show risk reductions of three percent long-chain n-3 supplements protect by six percent, and the surprise of more potent effects was that supplementary intakes with n-6 fatty acids protect by 14 percent. In relation to diet and prospective risks of coronary disease, Chowdhury and colleagues conclude essentially ‘no effects’ with saturates or with n-6 polyunsaturates, or with monounsaturates, but some lower risk with dietary n-3 polyunsaturates. Their final statement is, ‘current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.’ There were some academic responses to the Chowdhury review and some corrections were made post publication. The most immediate critique came the epidemiologists at the Harvard School of Public Health (although one of the HSPH staff, Dariush Mozaffarian, was in fact also a co-author of the Chowdhury review). Professor Walter Willett and colleagues challenged the lack of effect described for n-6 fatty acids, and specifically corrected some of the data used in the review. Major studies that did show 22
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significant inverse associations between intakes of polyunsaturated fat intake (mainly as n-6) and the risk of coronary disease had not been included by Chowdhury. Further, Willett and colleagues also stated that most of the monounsaturated fat consumed in the studies were from red meat and dairy sources, and that the findings might not apply for analysis of plant source monounsaturates. The Harvard experts state, “the conclusions…regarding the type of fat being unimportant are seriously misleading and should be disregarded.” It is striking, however, that Willett and colleagues make no comment on the observations by Chowdhury of ‘no effect’ for intakes of saturates. Other critiques, reported in Science magazine by K Kupferschmidt, are that diets replacing saturated fats with carbohydrates, and more dramatically diets with lower intakes of monounsaturates and polyunsaturates with higher energy intakes from carbohydrates, have been shown to increase the risk of coronary disease. Professor Mozaffarian, the man in the uncomfortable position of straddling two stools, as both author and critic of his own paper, stated that he was not happy with the conclusions of the paper about polyunsaturated fats (but he supported the no effects for mono and saturated fats). Less impressive responses by the University of Cambridge researchers to the general excitement about the paper, was that the main problem had been that the paper had
Cholesterol: saturated fats been, “wrongly interpreted by the media” (?), and that “more good trials were needed”. In fact, the paper is perhaps a general call to consider the limits of meta-analysis in relation to the population assessment of dietary data. Walter Willett was concerned that while drug trials are often a similar design, so it is possible to combine results, this was not true for nutritional studies, which vary widely in how they are set up. “Often strengths and weaknesses of individual studies get lost.” A similar concern was expressed by Professor Bruce Griffin of the University of Surrey, to a London meeting of the Guild of Health Writers in September 2014. Many of the individual studies included in the review by Chowdhury and colleagues showed clear effects of fatty acids on coronary risk, but these were lost when data were merged. He illustrated the concept with the discrete traits of items within a fruit bowl, which become less distinct and identifiable when the same items are mashed into a blended salad or smoothie. About half of adults in the UK have elevated blood cholesterol levels, above 5.2 mmol/L.
Current dietary intakes of saturated fats in the UK diet (as reported in the four year rolling programme of the National Diet and Nutrition Survey) are about 12.0-13.3% of energy, which is higher than the recommended amounts of no more than 10 percent of energy. Dietary fat modification appears to result in more successful outcomes in preventing cardiovascular disease than fat reductions (Hooper, 2011) and, while saturates may be less ‘bad’ than current dietary guidelines suggest, data supports the inclusion of monounsaturates and polyunsaturates in the diet (rather than some replacement of fats with carbohydrates). Possible future reviews of dietary public health recommendations on saturated fats will certainly consider current evidence, and dietitians will be the authoritative channels to communicate the up-to-date guidance, whether constant or changed. However, a problem of today for all health professionals, is the occasional clash between the near-daily outcomes of latest published evidence and the long-developed guidelines and policies that guide medical advice.
Information Sources: • Chowdhury R, Warnakula S, Kunutsor W and colleagues (2014). Association of Dietary, Circulating and Supplement Fatty Acids With Coronary Risk; A Systematic Review and Meta-analysis. Ann Intern Med 2014; 160: 398-406 • Hooper L et al. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database of Systematic Reviews 2011, Issue 7 • Kupferschmidt K. Scientists fix errors in controversial paper about saturated fats. Accessed from: http://news.sciencemag.org/health/2014/03 • Malhotra A. Saturated fat is not the major issue. BMJ 2013; 347: f16340 • Willett W, Sacks F, Stampfer M. Dietary fat and heart disease study is seriously misleading. Accessed from: www.hsph.harvard.edu/ nutritionsource/2014/03/19
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NHDmag.com NHDmag.com November 2014 - Issue 99
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TASTE. A RECIPE FOR RECOVERY Independent research shows that 70% of people prefer the taste of Ensure Compact to that of the leading competitor.1* And since taste is most important when it comes to patients taking their ONS,2 itâ&#x20AC;&#x2122;s no surprise that Ensure Compact also boasts 99% compliance,3** which supports patient recovery.4
1. Data on File. Abbott Laboratories Ltd., 2013 (Ensure Compact Palatability Research). 2. kasHČ&#x2DC;SP ;. et al. Turk J Gastroenterol 2013;24(3):266-272. 3. Data on File. Abbott Laboratories Ltd., 2013 (Ensure Compact Compliance Research). 4. /\IIHYK .7 et al. Clin Nutr 2012;31:293-312. ,UZ\YL *VTWHJ[ ]Z -VY[PZPW *VTWHJ[ ]HUPSSH Ă&#x2026;H]V\Y W# "U$ 6SKLY HK\S[Z HZRLK [V KYPUR IV[[SLZ WLY KH` MVY KH`Z U$ +H[L VM WYLWHYH[PVU! 4HYJO Í&#x201A;Í&#x201A;9?(50
bariatric surgery
Too Lean a Service? Moving on from the NCEPOD report on Bariatric Surgery Health professionals who arenâ&#x20AC;&#x2122;t involved in bariatric surgery may have missed the launch of the NCEPOD report in October 2012, but for those of us working in this specialist field, it was of great interest. For myself, it was the culmination of several monthsâ&#x20AC;&#x2122; work as an NCEPOD advisor. Gail Pinnock Specialist Bariatric Surgery Dietitian, Homerton University Hospital NHS Foundation Trust
Gail has worked in bariatric surgery for 10 years and is a council member of the British Obesity and Metabolic Surgery Society (BOMSS). She is a clinical advisor for the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) bariatric surgery report and is currently working on her doctorate at the University of Bath.
Bariatric surgery
NICE guideline CG 43(1) acknowledges that bariatric (obesity, weight loss or metabolic) surgery is a viable option for the morbidly obese, providing specific criteria have been met (Table 1). There must also be documented evidence that patients have attended a specialist Tier 3 (non-surgical) weight management service (2). Bariatric surgery is considered to be the most effective long-term treatment of morbid obesity (3, 4). The maximum weight loss depends on the surgical procedure and may range from 45 percent to 75 percent of excess body weight. The benefits of surgery are well documented with improvement of co-morbidities occurring in a significant number of patients (5, 6). Data from the National Bariatric Surgery Registry (NBSR) shows that remission of Type 2 diabetes occurs in 85.5% of patients two years after surgery (7).
It is becoming increasingly more common, and dietitians within both the acute and community settings are likely to come across these patients. Background to NCEPOD
NCEPOD, previously called the National Confidential Enquiry into Perioperative Death, was established 25 years ago. Its remit was the review of surgical and anaesthetic practice, but over the years this has been extended to cover all specialties in surgery and medicine, apart from Maternal and Child Health. As its change of name to the National Confidential Enquiry into Patient Outcome and Death implies, it is no longer interested only in the cause of death, but also in the delivery and quality of care. NCEPOD reports are based on peer review of collected data. It is a charity and independent of the Department of Health and professional associations.
Table 1: NICE criteria for surgery Criteria for surgery Aged 18 and over and children who have reached physiological maturity BMI 35kg/m2 with associated co-morbidities such as Type 2 diabetes, high blood pressure, obstructive sleep apnoea etc, that could be improved with weight loss BMI >40kg/m2 BMI >50kg/m2 may be considered in the first instance as a treatment option Appropriate non-surgical measures such as diet and exercise have been tried with no beneficial weight loss No clinical or psychological contra-indications Comprehensive multidisciplinary assessment Commits to long-term follow up NHDmag.com November 2014 - Issue 99
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bariatric surgery
14 percent of hospitals performed surgery on patients who did not meet NICE criteria. Call for reviewers
In May 2011, NCEPOD sent out a call for healthcare professionals working in bariatric surgery to apply to be clinical advisors for their forthcoming study, the primary aim of which was to investigate variation in care and identify areas for improvement. I was fortunate to be selected and joined a team comprising bariatric surgeons, physicians, anaesthetists, two dietitians, three nurses and a physiotherapist.
visors, in order to ensure consistency with our data reviewing process. At subsequent meetings, as well as reviewing case notes and inputting data, we were encouraged to discuss cases of interest with other advisors. In order to ensure consistency between advisors, duplicate cases were included at each meeting. The resulting views and opinions of the advisors were used to inform the final report and subsequent recommendations.
Data collection
Findings of the report
All hospitals in England, Wales and Northern Ireland, both NHS and private, which carried out bariatric surgery between 1st June and 31st August 2010 were included in the study. Case note extracts were collected from a random sample of patients and all identifiable information removed. In addition, two questionnaires were sent out to each participating hospital: firstly, a clinical questionnaire to be completed by each surgeon requesting information on the referral process and pre-assessment, the operation, the inpatient episode and followup; secondly, an organisational questionnaire to the hospital requesting details about facilities and equipment available for morbidly obese patients. Over the next six months, we each attended at least four advisor meetings where we reviewed the collected data. Whenever possible, representatives from all healthcare professions were present. All aspects of the bariatric pathway were assessed from referral to six months post surgery. The following data was collected: • Quality and appropriateness of referral • Appropriate multi-disciplinary team (MDT) and MDT process • Management of co-morbidities • Pre-, intra- and post-operative care • Prolonged ICU stays • Surgical and medical complications • Discharge, follow-up and/or readmissions within six months • Organisational factors At the initial meetings, each of us was expected to present one of their allocated cases to the other ad26
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The report Too Lean a Service? was launched in October 2012 (8). A full copy of the report can be found on the NCEPOD website: www.ncepod.org. uk/2012bs.htm. Below is an overview of the main findings, but I will concentrate on those issues that have a significant relevance to dietitians. The report acknowledges that bariatric surgery is effective, but that it is frequently portrayed as being a ‘quick fix’. Surgery is only part of the solution and not appropriate for all patients. Obesity is a multi-factorial condition and requires an experienced multi-disciplinary team to provide the best possible treatment options for their patients. Issues of concern were encountered at all stages of the bariatric pathway from inappropriate referrals, poor assessment procedures and discharge summaries to inadequate follow-up. • 14 percent of hospitals performed surgery on patients who did not meet NICE criteria. • 28 percent of patients had no documented evidence of having received any input from a dietitian at any stage prior to surgery. • In only 29 percent of cases was there any evidence of psychological input despite the fact that psychological disorders are common in obese patients. • Only 55 percent of hospitals held MDT meetings for bariatric patients. • 24 percent of consent forms did not contain appropriate information that would allow patients to make an informed decision about surgery. • 20 percent of discharge summaries were judged to be poor or unacceptable with insufficient clinical and drug information.
bariatric surgery
28 percent of patients had no documented evidence of having received any input from a dietitian at any stage prior to surgery. • One third of patients reviewed had inadequate follow up; either the timing was poor or it was not given by an appropriate member of the team such as a surgeon or dietitian. Advisors were asked to grade the level of care that patients received from referral to follow-up. In only 32 percent of cases did we find that overall care was good. In the vast majority of cases we found that there was room for improvement in either the clinical and/or organisational care of the patient. Worryingly, we found that seven percent of patients had less than satisfactory care. Many of the core problems highlighted in the report are generic to all specialties in the NHS and have also been highlighted in previous NCEPOD reports. These problems result from a failure to do simple things methodically and well (Too Lean a Service? 2012). On a positive note, there is considerable support in the report for the dietetic profession and it reflects well on the role of dietitians. In his foreword to the report, the NCEPOD chairman Mr Bertie Leigh, states that, for him, the main lesson from this report reinforces one of the findings from a previous study on parenteral nutrition entitled A Mixed Bag published in 2010: “…namely that the value of dietitians and nutritionists is not sufficiently recognised by the modern health service.” He continues: “It is extraordinary that both the private sector and the NHS should offer a surgical solution to people suffering from an extreme disorder of diet without involving the dietitian. If changes in eating behaviour are to be sustained, the advice of the dietitian will be invaluable.” The report has put forward a number of recommendations and some of these that are pertinent to dietitians are highlighted below: • All patients should have access to a full range of specialist professionals in line with NICE guidelines. • Patients considered for surgery should receive dietary assessment and education preferably prior to referral but definitely before surgery. • Given the potential for significant metabolic change as a result of surgery and its dietary
consequences, patients should have clear postoperative dietary guidance • Each patient should have a clear long-term follow-up plan that must include appropriate levels of surgical, dietetic, GP and nursing input. Publication of Guidelines and Codes of Practice
So, how has bariatric surgery practice progressed in the two years since the NCEPOD report was published? The British Obesity and Metabolic Surgery Society (BOMSS) is a professional society of surgeons and allied health professionals (AHPs) involved in obesity management. The aim of the society is threefold: to promote the development of high quality centres of bariatric surgery, to educate and train surgeons and AHPs and guide commissioning policy. It is increasingly regarded as a respected authority on standards within bariatric surgery. In the same month that the NCEPOD report was published, BOMSS launched its own Standards for Clinical Services and Commissioning Guidelines. These set out the core requirements for a bariatric service, covering the healthcare professionals constituting the multidisciplinary team, hospital facilities, equipment and the referral process and patient pathway. In addition, BOMSS published a Code of Ethics intended as a guide to assist all members in achieving the highest level of ethical conduct in their practice. Following a review of internet advertising of bariatric surgery, it found a wide variation in standards. This led to the publication of a Statement on Advertising Practice for Bariatric Procedures. In March 2013, BOMSS published Professional Standards, guidelines covering the training of both surgeons and non-surgeon members of the MDT. BOMSS requires that all members be trained appropriately, have relevant experience in bariatric surgery and be committed to data collection via the National Bariatric Surgery Registry (NBSR). Members of the MDT should be registered with their own professional regulatory bodies. NHDmag.com November 2014 - Issue 99
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bariatric surgery Anyone who works in bariatric surgery will be aware that there have been no standard guidelines for the monitoring and supplementation of the bariatric patient. A survey of BOMSS members showed considerable variation in practice, suggesting a need for standardised guidelines. A comprehensive review of existing literature and guidelines by a working party led by Ms Mary O’Kane, has resulted in recommendations for safe practice in the UK. BOMSS Guidelines on Peri-operative and Post-operative Biochemical Monitoring and Micronutrient Replacement for Patients undergoing Bariatric Surgery was launched in October this year. The Education, Training and Research subcommittee of BOMSS is active in providing training courses for surgeons and AHPs. Training days are held at the start of the BOMSS Annual Scientific meetings and are inclusive for all members of the society. There are topics appropriate for all members of the MDT as well as specialist sessions for surgeons and AHPS. Members of the BOMSS Dietitians’ Committee offer introductory and advanced courses specifically for dietitians. The response to these courses has been very positive and the Committee is in the process of redeveloping these courses so that they will appeal to all AHP members. Specialist bariatric surgery centres are well equipped to deal with the potential complications that may arise after surgery. To raise awareness in non-specialists, BOMSS has produced emergency guidelines. The first of these, Emergency Department Management of the Bariatric Patient was developed as an aid for initial assessment and management of patients presenting to A&E or acute assessment units. It is an ‘at-a-glance’ traffic light style poster displaying presentation symptoms and required actions. The second of these guidelines was launched in August 2014. The Primary Care Management of Post-Operative Bariatric Patients is a poster specifically for general practitioners. The
poster displays a range of symptoms and complications categorised in traffic light colours that warrant emergency, urgent or routine attention. The launch of the Commissioning Guide: Weight Assessment and Management Clinics (Tier 3) in March 2014 was the culmination of a NICE accredited process led by several Royal Medical Colleges, BOMSS and the British Dietetic Association amongst others. It is intended to help with the commissioning of Tier 3 services and improve access to these services across the country. It should be used alongside the commissioning policy for Complex and Specialised Obesity Surgery Services (9). BOMSS has been pro-active in producing guidelines that will address issues raised by the NCEPOD report and that ensure the safe and effective management of bariatric surgery patients. Guidelines can be accessed at www.bomss.org.uk What have I gained from being involved in NCEPOD and BOMSS?
It has given me the opportunity to acquire some new skills and refine some old ones, which have contributed to my professional development. This includes everything from representing the interests of dietitians and other AHPs in my capacity as an elected Council member of BOMSS, the challenge of being presented at NCEPOD with medical information outside of my own area of expertise and trying to make sense of it, to the time management skills needed to work to exacting deadlines. Would I encourage other dietitians to apply to be part of future NCEPOD reports? Yes, I would. It’s a wonderful opportunity to work with other healthcare professionals and gain knowledge and insight into their specific areas of expertise. It is also exciting to be involved in a nationwide project that aims to improve the quality of patient care whilst raising the profile of dietitians and the dietetic profession.
References 1 NICE (2006). Obesity: Guidance of the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence 2 Commissioning Guide: Weight Assessment and Management Clinics (tier 3). March 2014. Sponsoring organisation: BOMSS 3 Schweitzer M, Lidor A, Magnuson T (2006). Bariatric Surgery, Health and Treatment Strategies in Obesity. Adv Psychosom Med. 27, 53-60 4 Shah M, Simha V, Garg A (2006). Long-term impact of bariatric surgery on body weight, co-morbidities and nutritional status. Journal of Clinical Endocrinology and Metabolism. 91 11, 4223-4231 5 Karlsson J et al (2007). Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. International Journal of Obesity, 31: 1248-1261 6 Smith B et al (2008). Remission of diabetes after laparoscopic gastric bypass. The American Surgeon. 74: 948-952 7 Welbourn R et al (2010). The National Bariatric Surgery Registry: First Registry Report to March 2010. Dendrite Clinical Systems Ltd: Henley-on-Thames, 2010 8 NCEPOD (2012). Too Lean a Service? A review of the care of patients who underwent bariatric surgery. National Confidential Enquiry into Patient Outcome and Death, October 2012 9 www.ncepod.org.uk/2012bs.htm 10 NHS Commissioning Board (2013). Clinical Commissioning Policy AO5: Complex and Specialised Obesity Surgery April 2013
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Nutrition and cancer care
Nutrition support for head and neck oncology patients having radiotherapy
Jennifer Hoare, Senior Macmillan Oncology Dietitian, Mount Vernon Cancer Centre Jennifer graduated in 2008 with a Biology degree and went on to qualify as a dietitian. Since qualifying, Jennifer has specialised in head and neck oncology and now provides a weight management service to breast cancer patients.
Head and neck cancer (HNC) includes malignant tumours of the oral cavity, nasal cavity, paranasal sinuses, salivary glands, pharynx, larynx and lymph nodes in the neck, but excludes tumours of the brain and malignant melanomas (1) (Diagram 1). Cancers of the head and neck are the sixth most common cancer worldwide (2) and represent approximately 8,800 new cases and 2,700 deaths per year in England and Wales (1). Diagnosis typically occurs from age 40 upwards with a prevalence of 3:1 ratio male to female (3). Alcohol consumption and tobacco use are the primary risk factors; however, in non-smokers and drinkers the human papillomavirus is increasingly recognised as a causal factor (4). This article will examine the nutritional implications of radiotherapy in HNC patients. Malnutrition
Malnutrition in cancer patients is an indicator of poor prognosis (5). At diagnosis, greater than 50 percent of HNC patients are malnourished and during multimodality therapy, 80 percent will experience significant weight loss (4). Dietary habits and detrimental lifestyle factors, such as alcohol misuse, predisposes these patients to malnutrition (1). Furthermore, radiotherapy produces various acute symptoms that impact on oral intake. Malnutrition in cancer patients can result in impaired wound healing, muscle weakness, depression,
decreased quality of life, lethargy and increased risk of infection, hospitalisation, interruptions to treatment and increased mortality rate (1). Nutritional implications
Patients undergoing radical (curative) radiotherapy typically receive a dose of 60 to 70 gray. This dose is fractionated; patients receive approximately 2.0 gray once a day, five days a week over six to seven weeks. Head and neck radiation can result in a wide spectrum of oral complications caused by the irradiation of the normal tissue surrounding the tumour. Consequently, patients have substantial symptom burden usually reporting one or more of the following symptoms by week two or three of treatment: Oral mucositis is the most common and debilitating effect of radiotherapy characterised by the inflammation and ulceration of the mucous membranes lining the mouth (3, 4). Severe mucositis is associated with increased pain and
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nutrition and cancer care Diagram 1: Key anatomical sites in the head and neck region.
Oral mucositis is the most common and debilitating effect of radiotherapy characterised by the inflammation and ulceration of the mucous membranes lining the mouth
Diagram adapted and created by Dr S Bullers.
impairment of the patient’s ability to eat and swallow. Research has shown that these patients are prone to interruptions in treatment, hospitalisation, oral candida infections, poor nutritional status and weight loss (6). Patients with mucositis should avoid acidic, spicy and rough foods and consume soft, moist foods, progressively moving onto a puree then liquid plan. Taste dysfunction includes a wide range of taste changes from salty, sweet and bitter through to a complete lack of taste. This can result in a lack of interest in food, decreased intake, weight loss and nutritional compromise. Taste recovery can be anticipated three to six months post-treatment, although changes may be permanent. During treatment, bland foods are advised, whereas posttreatment, the use of seasoning, sharp or strong flavours can improve the palatability of meals. Xerostomia (dry mouth) is universal in patients receiving radiotherapy to areas that encompass the salivary glands (3). It can adversely affect intake since it alters one’s ability to move food through the mouth and form a food bolus, making swallowing difficult. Consuming meals with extra sauce or foods naturally high in water, together with frequent sips of fluid during and between meals, can ease discomfort. Foods high in starch (i.e. bread, potato) or tough textures like meat can exacerbate dryness. The use of sauce or a high fat product can improve the consistency; however, some patients may continue to struggle. Dysphagia, an inability to swallow, or problems swallowing, may be due to pain, medication or a mechanical or functional obstruction (4). An assessment of swallow by a speech therapist is essential to determine the patient’s risk of 30
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aspiration, whether oral intake is possible and, if so, the type of texture modified dysphagia diet required (4, 7). Excess mucus production is distressing for the patient; it can render eating, drinking and speaking challenging. The mucus triggers nausea, gagging and vomiting, further compounding the patient’s inability to maintain adequate nutrition and hydration. Appropriate hydration should be stressed, as adequate fluid intake can improve the viscosity of the secretions facilitating removal. Patients may also struggle with nausea, vomiting, constipation or diarrhoea. It is important that patients receive appropriate medications to control these symptoms, as they may impair intake and increase nutrient and fluid losses, placing the patients at greater risk of dehydration and malnutrition. The long-term consequences of radiotherapy include xerostomia, dysphagia, trismus caused by radiotherapy induced fibrosis of the masticatory muscles (4) and/or osteoradionecrosis, death of an area of bone caused by poor blood supply (3), all which can influence nutritional status. Nutrition Support
Nutritional interventions during and post-radiotherapy include dietary counselling and modification, oral nutritional supplements or enteral nutrition via tube feeding. At Mount Vernon, this patient group is seen weekly by a dietitian and speech therapist. Prior to the development of oral complications, all patients receive advice on food fortification, a soft, moist diet and the importance of hydration and nutrition during radiotherapy.
nutrition and cancer care Given that a patient’s condition can change rapidly, it is important to provide comprehensive dietary plans that consider anticipated changes to oral intake. This patient group often requires much more intensive nutritional support with the early use of oral nutrition support (4). When oral intake becomes insufficient to meet nutritional requirements, total or partial enteral nutrition support may be necessary to prevent weight loss and maintain hydration and nutritional status. At present, there is no consensus criterion on gastrostomy placement in HNC patients. However, prophylactic tube placement is recommended if the cancer is likely to interfere with swallowing, or if mucositis is anticipated and where prolonged enteral nutrition will be required (4, 8). Often establishing a patient on an enteral feed is easier than weaning them off their feed onto a normal oral diet. For many, knowing that nutrition, hydration and medical needs can be achieved via the gastrostomy is an immense source of comfort. Therefore, our role as dietitians includes a great deal of psychological and emotional support.
References 1 DAHNO ninth annual report: National head and neck cancer audit (2013). London: the information centre for health and social care. Available from: www.hscic.gov.uk/catalogue/PUB14257/clin-audi-supp-prog-head-neckdahn-12-13.pdf [Accessed 01 September 2014) 2 Parkin DM, Bray F, Ferlay L and Pisani P (2005). Global Cancer Statistics, 2002. CA: A Cancer Journal for Clinicians. 55 (2): pp74-108 3 National Institute of Clinical Excellence (NICE) (2004). Improving outcomes in head and neck cancers - The manual. London: NICE 4 Roland NJ, Paleri V (eds) (2011). Head and Neck Cancer: Multidisciplinary Management Guidelines. 4th edition. London: ENT UK 5 Arends J, Bodoky G, Bozzetti F, Fearon K, Muscaritoli M, Selga G, van Bokhorst-de van der Schueren MA, von Meyenfeldt M, Zürcher G, Fietkau R, Aulbert E, Frick B, Holm M, Kneba M, Mestrom HJ, Zander A (2006). ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology. Clin Nutr. 25: pp245-59 6 Vera-Llonch M, Oster G, Hagiwara M and Sonis S (2006). Oral mucositis in patients undergoing radiation treatment for head and neck carcinoma. Risk factors and clinical consequences. Cancer. 106 (2), pp329-336 7 National Patient Safety Agency (NPSA) Dysphagia Expert Reference Group (2011). Dysphagia diet food texture descriptors. Available from: www. thenacc.co.uk/assets/downloads/170/Food%20Descriptors%20for%20 Industry%20Final%20-%20USE.pdf [Accessed 20 September 2014] 8 National Collaborating Centre for Acute Care (2006) Nutrition support in adults Oral nutrition support, enteral tube feeding and parenteral nutrition. London. www.nice.org.uk/CG32 [Accessed 10 September 2014] The Mount Vernon Cancer Centre is a regional cancer centre that delivers specialist radiotherapy and chemotherapy services to oncology patients. Patients with head and neck cancer undergoing radiotherapy or chemoradiotherapy form the majority of the dietetic caseload. This group has an increased risk of malnutrition and dietetic intervention is essential to ensure optimal nutritional status, reduce weight loss and interruptions to treatment.
Nutritional requirements
Oncological treatment may influence resting energy expenditure (5). Patients with cancer are mildly hypermetabolic with excess energy expenditure between 138-289kcal/day (4). In general, the following is suitable for non-obese ambulatory patients: Energy: 25-35kcal/kg/day, protein: 1.0-2.0g/kg/day, fluid: 30-35ml/kg and vitamins and minerals as per recommended daily amounts unless deficient (4, 5). The goals of nutrition support are to prevent and treat malnutrition, prevent hospital admissions and interruptions to treatment and achieve optimal nutrition and hydration. Conclusion
Poor nutrition has a negative impact on a patient’s ability to cope with the radiotherapy treatment as well as recovery time. Radiotherapy to the head and neck region can affect many activities that we take for granted, such as eating, drinking, breathing and speaking and unfortunately these effects may be permanent. Consequently, these patients need long-term support and the oncology dietitian plays a pivotal role in cancer survivorship. It is a demanding, but rewarding job. NHDmag.com November 2014 - Issue 99
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child weight management
Child weight management app Finalising an e-resource for clinical dietetic practice.
Carol Raaff Paediatric Dietitian Child Weight Management, PhD Researcher Staffordshire and Stoke-on-Trent Partnership NHS Trust
The previous two NHD articles introduced the rationale and design concept (1) and then documented the development phases (2). This article brings the app development to a close and offers a reflection on the process as a whole. Adding the finishing touches
The final stages of development have included adding suggestions for how each screen could support dietetic practice (such as in Figures 1 and 2), providing ideas on how the app could be used with children and parents. Another finishing touch is the addition of sound. Sound can be distracting within a faceto-face consultation as it can interfere with the verbal discussion between the family and the dietitian. Care has therefore been taken to select short sound clips that compliment onscreen animations (3). The highs and lows of developing an app
Carol has been a paediatric dietitian for nine years. She now works in a communitybased weight management service, whilst researching the potential for e-resources to improve dietetic communication with this patient group.
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This project has undoubtedly been a rollercoaster ride. To begin with, it took some time to get to grips with the software. I have limited experience of software coding that dates back to a point in time some 12-years ago and I am by no means competent in the field. As a result, the development platform that I used to animate the images and create interactivity was selected, in part, because of the claim: ‘no coding required’. Unfortunately, it quickly became apparent that while this is true for simple animations, for the other half of the app to work, I would need to grapple with Javascript. This was daunting, and at times almost overwhelming.
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The software wasn’t the only thing that presented a challenge; I also needed to learn how to create successful interactive animations. Having laboured for several weeks over the structure of the first few screens, I presented my efforts to my supervisors who were very encouraging and helpfully gave me the following advice: “make use of the technology”. It made me rethink my designs, so as to capture the essence of the message both simply and interactively, making use of opportunities for the user (or patient) to be in control. My first NHD article (1) contains my design journey of the Growth and BMI section of the app, which illustrates this point further. As with anything, however, having mastered a tool, the more competent you become at using it, the more success you have at what you are able to create. It is incredibly rewarding to bring an idea to life, finally getting an interaction to work after days or weeks of wrestling with it. Tips and advice
Several dietitians have told me that they have been thinking about undertaking a similar project, so I thought it would be useful to share some of what I have learnt. Images
It may seem obvious to some, but all of the images used in an app need to be created or purchased. Drawing your own is possibly cheaper, but it does cost you time (it took me approximately four weeks). What you gain is greater control over the style of your app, consistency (purchasing different images from different sources can lead to an incoherent
child weight management Figure 1: Suggested instructions for clinicians - a Time to Think screen
Figure 2: Suggested instructions for clinicians - an Eat Well screen
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child weight management
Designing an app from scratch, without other points of reference, can be professionally challenging. Having one or two other interested dietetic colleagues for support is invaluable.
and less professionally finished product), and the freedom to customise the images to what is needed in your animations. Having researched the most efficient way, I found that vector images can be created rapidly, altered easily and reused. Development platform
Choosing an appropriate development platform - used to create the app in - is important. I considered four aspects: ease of use, functionality across all web browsers (HTML5 and CSS are the accepted standard for building Internet-enabled content (4)), purchase price and how it could be packaged into a downloadable app. Once the hard work has been invested into the development, making the app available on an app store is costly and it would be worthwhile getting professional advice on the options available before embarking on the project. Feedback
Designing an app from scratch, without other points of reference, can be professionally challenging. Having one or two other interested dietetic colleagues for support is invaluable. These are the people you can go to for ongoing feedback, who will tell you when you are hitting the mark (and when you are missing it by a mile). Depending on the dietetic speciality, it may be necessary to form a multidisciplinary team, including clinicians with relevant skills and expertise, e.g. specialist nurse or paediatrician.
Inviting wider professional collaboration is both clinically important (5) and ethical (6). This could be done in several ways: focus groups, carefully crafted online questionnaires, or you may wish to set up a blog (e.g. http://dietitian-feedback.weebly.com) to provoke wider discussion, suggestions and comments. Specific questions offer guidance to those accessing the blog, enabling helpful feedback on specific design aspects. Testing out the app
Testing the app with the intended patient group is important. In theory, this can be done at any stage, but is probably most helpful towards the end, when there is something to see and interact with (and the app is in its intended format). Initial testing should be done with non-patient peers of the patient group and then with patients themselves (6). Final testing with patients will need agreement and support from your employer (or relevant organisation). Next steps
A feasibility study is being planned to gauge the extent to which the app improves child-dietitian treatment dialogue. Effective e-resources may serve as scaffolding to the younger child, for conversations they have with the dietitian. This may in turn improve understanding, involvement, motivation and even compliance to lifestyle behaviour change (1). My hope is that we would begin to develop and research apps for other areas of dietetic practice and, in so doing, improve treatment options for our patients.
References 1 Raaff C (2014). Child weight management app - downloading part 1 of 3: Designing an e-resource for clinical dietetic practice. NHD Magazine. 96: 38-41 2 Raaff C (2014). Child weight management app - downloading part 2 of 3: Developing an e-resource for clinical dietetic practice. NHD Magazine. 97: 38-41 3 Najjar LJ (1996). Multimedia learning and information. J Ed Multimed HyperMed. 5(2): 129-150 4 W3C (2013). Web designs and applications. Available at: www.w3.org/standards/webdesign [accessed 9 October 2014] 5 HCPC (2012). Standards of conduct, performance and ethics. London, Health and Care Professions Council 6 Doherty G, Coyle D, Matthews M (2010). Design and evaluation guidelines for mental health technologies. Interact Comp. 22(4): 243-252
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means giving the whole family something to smile about
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gluten-free guide
Gluten-free resources and information BDA Gastroenterology Special Interest Group (GSG) bda.uk.com 0121 200 8080, info@bda.uk.com Coeliac UK coeliac.co.uk, 0845 305 2060 British Society of Gastroenterology bsg.org.uk, 020 7935 3150, t.smith@bsg.org.uk Live Gluten Free liveglutenfree.co.uk, 01738 23 70 70, info@liveglutenfree.co.uk Gluten Free for RDs glutenfree.com, customerservice@glutenfree.com Food Intolerance Network food-intolerance-network.com, officeuk@food-intolerance-network.com CORE - fighting gut and liver disease corecharity.org.uk, 020 7486 0341, info@corecharity.org.uk DS-gluten free dsglutenfree.com/en/, 0800 954 1981, info@dsglutenfree.co.uk Dr Schar Institute drschaer-institute.com, 0800 988 8470, professionals@drschaer.com Glutafin glutafin.co.uk, 0800 988 2470, glutenfree@glutafin.co.uk
Juvela supporting healthcare professionals juvela.co.uk/hcp, 0800 783 1992, Nutrition Society nutritionsociety.org, 020 7602 0228, office@nutritionsociety.org.uk Patient UK patient.co.uk Primary Care Society of GB pcsg.org.uk, 0207 836 0088, secretariat@pcsg.org.uk Sure Foods Living surefoodsliving.com, 415-785-4980 (US), alison@surefoodsliving.com The Celiac Site (US) theceliacsite.com, 215-325-1306, info@celiaccentral.org Uni of Chicago Celiac Disease Centre cureceliacdisease.org, 773-702-7593 Celiac Disease and GF diet Information (US) celiac.com Celiac Disease Awareness Campaign (US) celiac.nih.gov, 1-800-891-5389, celiac@info.niddk.nih.gov Celiac Handbook (US) celiachandbook.com, hello@celiachandbook.com NHDmag.com November 2014 - Issue 99
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gluten-free guide Supplier Abel & Cole Ltd Against The Grain Almondy Baked To Taste Beanie's Health Foods Blue Lotus cakes Bounce Brookfarm Clearspring Clives Pies Community Foods Ltd Doves Farm Foods Ltd Dr Schar Droppa & Droppa Drossa Limited DS-gluten free Eco Green Store Ethical Superstore Feel Free Freego General Dietary Genius Gluten Free Glebe Farm Glutafin Gluten Free Foods Ltd Gluten Free Direct Gluten Free Kitchen Glu-2-Go Goodness Direct Granovita Green's Beers
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Website / Tel / Email
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abelandcole.co.uk 0845 262 6262 organics@abelandcole.co.uk againstthegrainfoods.com 01688 302 223 info@againstthegrainfoods.com almondy.co.uk 020 7795 8148 info@almondy.com bakedtotaste.co.uk 01404 47904 g-free@tiscali.co.uk beanieswholefoods.co.uk 0114 268 1662 info@beanieswholefoods.co.uk bluelotusdairyfreecakes.blogspot.co.uk/ 0116 299 8122 admin@bluelotuscakes.co.uk bouncefoods.com 0845 838 2579 Balls@bouncefoods.com brookfarm.com.au 0061 (02) 6620 9500 info@brookfarm.com.au clearspring.co.uk 020 8749 1781 info@clearspring.co.uk clivespies.co.uk 01364 642 279 sally@clivespies.co.uk communityfoods.co.uk 020 8208 2966 enquiries@communityfoods.co.uk www.dovesfarm.co.uk 01488 684880 mail@dovesfarm.co.uk drschaer.com/en/ 01925 865100 info.uk@drschaer.com droppaanddroppa.com 01237 420 417 enquiries@droppaanddroppa.com drossa.co.uk 020 3393 0859 orders@drossa.co.uk dsglutenfree.com/en/ 0800 954 1981 info@dsglutenfree.co.uk ecogreenstore.co.uk 01603 327962 rob@ecogreenstore.co.uk ethicalsuperstore.com 0845 009 9016 enquiries@ethicalsuperstore.com feelfreefoods.co.uk 08081 290 261 hello@feelfreefoods.co.uk freego.com/ 0844 6921333 generaldietary.com 0203 044 2933 info@generaldietary.com geniusglutenfree.com/en_GB 0845 874 4000 info@geniusglutenfree.com glebe-flour.co.uk 01487 773 282 office@glebe-flour.co.uk glutafin.co.uk 0800 988 2470 glutenfree@glutafin.co.uk glutenfree-foods.co.uk 020 8953 4444 info@glutenfree-foods.co.uk glutenfree-direct.co.uk 01757 289 200 info@gf-foods.co.uk glutenfreekitchen.co.uk 01969 622222 info@theglutenfreekitchen.co.uk lsglutenfree.com 01324 717 273 info@lsglutenfree.co.uk goodnessdirect.co.uk 0871 871 6611 info@GoodnessDirect.co.uk granovita.co.uk 01933 273 717 info@granovita.co.uk glutenfreebeers.co.uk 0161 456 4226 info@glutenfreebeers.co.uk
Various - online store inc meals, snacks, sauces, pasta, noodles, sweets
NHDmag.com November 2014 - Issue 99
Cookies, biscuits Cheescakes and tarts Pasties, pies, sausage rolls, quiches, tarts, cakes, bread, pastry, scones Fry's Meat replacement products and meals Cakes, brownies and breads Bounce healthy snack bars Macadamia products: muesli, nuts, mixes, snacks, oils Japanese & European foods inc miso, noodles, sauces, pasta, purees, spreads Pies, pasties, rolls, cakes, flapjacks, dips Dried fruits, nuts, seeds, herbs, spices, pulses, cereals, rice Various products - online store producer of gluten-free food: Glutafin and DS-gluten free Artisan bakers: breads, cakes, tarts, muffins, savouries Wide range of products inc biscuits, breads, pizza, pasta, mixes, sauces, pickles, marinades Various - online store Various - online store Various - online store Breads, Christmas, Eastern, Italian, sausages, sweets and savouries Various products - online store Breads, rolls, cookies, snacks, cheeses, communion wafers, pasta, baking products, prescriptions Bakery, frozen pies, pastry Flour, cake mixes, bread mixes, prescriptions, biscuits, cereal, pasta, noodles Breads, rolls, mixes, pasta, biscuits, crackers, prescriptions Various - online store Various brands - online store Online bakery - sweet and savouries batter mix, breadcrumbs, sauces, vinegar, gravy Various - online store Granola, juices, snacks, oils, quinoa, oils, condiments, sauces, pate, puree Beers and ales
gluten-free guide Supplier
Website / Tel / Email
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halenhearty.co.uk Hale and Hearty 020 328 27602 hello@halenhearty.co.uk hambletonales.co.uk Hambleton Breweries 01765 640108 office@hambletonales.co.uk heinz.co.uk/Products/Gluten-Free Heinz Deliciously Gluten Free range 0800 528 5757 via online form honeybuns.co.uk Honey Buns 01963 23597 thebee@honeybuns.co.uk hunterspuddings.co.uk Hunter's Puddings 01539 232 308 sales@hunterspuddings.co.uk ilumiworld.com/products Ilumi 0800 505 3232 shop@ilumiworld.com juvela.co.uk Juvela 0800 783 1992 info@juvela.co.uk kealthfoods.com Kealth Foods 01685 810058 info@kealthfoods.com livwellfoods.co.uk Livwell 0845 120 0038 info@livwell.eu lovemore-freefromfoods.com Lovemore Free From Foods 01685 813 545 lovemore@welshhills.com glutenfreefoodproducts.co.uk Mandy's Gluten Free 0845 4670701 admin@glutenfreefoodproducts.co.uk meridianfoods.co.uk Meridian Foods 01962 761 935 website.info@meridianfoods.co.uk glutenfreebutcher.co.uk Morley's of Swanland 01482 634 225 gf@glutenfreebutcher.co.uk mrscrimbles.com Mrs Crimble's 01256 393460 info@mrscrimbles.com munchyseeds.co.uk Munchy Seeds 01728 833 004 nibble@munchyseeds.co.uk nairns-oatcakes.com Nairn's 0131 620 7000 info@nairns-oatcakes.com naturalgrocery.co.uk Natural Grocery 01242 572 323 orders@naturalgrocery.co.uk naturallygoodfood.co.uk Naturally Good Food 02476 541990 orders@naturallygoodfood.co.uk plamilfoods.co.uk Plamil 01303 850 588 contact-us@plamilfoods.co.uk proceli.com Proceli 0034 93 784 83 82 info@proceli.com puredairyfree.co.uk Pure (Kerry Foods) 0800 783 4321 info@puredairyfree.co.uk rizopia.co.uk Rizopia 01992 581715 info@pgrhealthfoods.co.uk roleys.com Roley's 0031 33 463 0165 info@roleys.com sallyssizzlers.com Sally's Sizzling Sausage Co 020 7213 9474 sales@sallyssizzlers.co.uk simply-free.co.uk Simply Free 01582 840502 enquiries@simply-free.co.uk village-bakery.com The Village Bakery Melmerby 01768 898 437 info@village-bakery.com udisglutenfree.co.uk Udi's Gluten Free available at Tesco in Cheshire/Merseyside region warburtonsglutenfree.com Warburtons Gluten Free 0800 243684 www.newburnbakehouse.com/contact-us wellfoods.co.uk Wellfoods 01226 381 712 janet@wellfoods.co.uk wiltshirefarmfoods.com Wiltshire Farm Foods 0800 773 773 info@wiltshirefarmfoods.co.uk windmillorganics.com Windmill Organics 0208 547 2775 sales@windmillorganics.com
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book review
Body Respect What Conventional Health Books Get Wrong, Leave Out, and Just Plain Fail to Understand about Weight Review by Ursula Arens Writer; Nutrition & Dietetics
By Linda Bacon and Lucy Aphramor BenBella Books; 1st ed, Sep 2 2014 ISBN-1940363195 Price: £9.34
Fancy a challenge? You could jump into a cold pool. Or stay up all night reading poetry aloud for charity. Or run a long-for-you distance. Or, if you are a dietitian, you could read the book Body Respect.
Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula helps guide the NHD features agenda as well as contributing features and reviews
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Headline statements made on the cover of the book are, ‘mainstream health science has let you down; weight loss is not the key to health, diet and exercise are not effective weight-loss strategies, and fatness is not a death sentence’. British dietitian Lucy Aphramor and her American colleague Linda Bacon are champions of the ‘Health at Every Size’ (HAES) movement, which examines alternative (to traditional medical/dietetic) approaches to the treatment of overweight. Is there sufficient science to support the go-gently way to weight control? Is advising on the myriad permutations of, ‘eat less, move more’ really not the best way to help obese people? One immediate terminology edit: Bacon and Aphramor prefer the term ‘fat’ to overweight or obese. Fatness communicates a form of body diversity (like skin color or sexual preference), and is less the medical shorthand to communicate health status. Media headlines in September announced, ‘Prejudice against fat people as bad as racism, say scientists’, describing the view of Dr Sarah Jackson of University College London, that blaming and shaming fat people was
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counterproductive, and that fattism was the ‘last socially acceptable form of prejudice’ (The Times, cover, 11.9.14). The central theme of the book is that weight alone is not a reliable measure for many health outcomes, and that there should be a refocus of communications on lifestyle behaviours, and other health determinants, as more valid and effective ways to support fat people. The goals for health care interventions should be improved health and well being, and Bacon and Aphramor assert that many weight loss interventions do not provide this outcome, and further, may lead to health impairments and feelings of failure in fat people. The authors list various myths behind obesity treatments. Firstly, fatness does not decrease longevity. The much discussed research of Professor Katherine Flegel of the US Centers for Disease Control (CDC) concludes from analysis of data on three million Americans, that people who were overweight or mildly obese, did not have a lower longevity. Myth two is that diet and exercise are effective weight loss techniques. Bacon and Aphramor state that the vast majority of people who intentionally try to lose weight, will regain all weight lost.
book review Many weight loss studies were open to methodology critique, such as cherry picking of participants, or short-period monitoring. Claims of benefit were made before weight regain trajectories had flat lined, and of concern was the notable absence of attempts to consider possible adverse effects of diet restrictions or the weight yo-yo cycle. The third myth is that weight loss improves health. Some claimed health benefits of different diets and greater physical activity may be due to these two factors, but not due to changes in body weight. Eating more beans and broccoli and doing fresh-air walks may improve health, even without energy restriction and weight loss. The more wholesome method of support for those with anxieties over fatness is the transition from the rules-and-measurements focus of traditional diets, towards compassionate self-care. This means more attuned eating and increased mindfulness over opportunities for movement and health behaviours that support feeling well (such as adequate sleep and planned leisure). Chapter 6 is about eating well. Bacon and Aphramor reassure readers that having confidence in their innate fullness and appetite sensors provide a better guide to weight regulation than calorie counting, and that attuned eating rather than overriding hunger signals, is the way to better physical and mental health. Carbohydrates should include nutrient-dense choices from vegetable, beans, fruits and wholegrain sources.
Sugary and refined carbs are not great choices, but donâ&#x20AC;&#x2122;t avoid these, as cognitive restraint disrupts effortless eating. Rather, include wholesome carb foods first, but allow yourself tasters of any other carb foods to match social situations. Proteins are essential, of course, but the authors do not suggest any focus on this nutrient, as people who get sufficient calories always get sufficient protein. Low-fat diets are not given support, and healthy fats are useful; avocados are advocated, as is oily fish and flax seeds. Readers are advised not to avoid fat, but rather to explore healthy (fatsource) foods. In place of, rather than as well as, ice cream and doughnuts? The book ends with a case description in oldstyle and new style approaches to fatness. No commands and critiques, but rather shared and sympathetic plans for healthier lifestyle decisions that fit into stressed and perhaps unhappy life situations. Perhaps kind chats cannot solve the real medical issues facing the health risks of obesity, and for all the (perhaps valid) critiques of traditional weight loss therapy, there is no real evidence that health-not-weight approach really does deliver (health). However this book by Aphramor and Bacon provides robust data to support many of the points made, and further, they offer many thoughtful and helpful comments to improve the care of fat people who want to improve their lifestyles. This book is an excellent addition to the dietitian reading list.
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web watch
web watch Online resources and useful updates.
Food standards for NHS hospitals The Department of Health has published ‘The Hospital Food Standards Panel’s report on standards for food and drink in NHS hospitals’. The report looks at standards relating to patient nutrition and hydration, healthier eating across hospitals and sustainable food and catering services. NHS adoption of the recommended standards will be required through the NHS contract meaning that hospitals will have a legal duty to comply with the recommendations. www.gov.uk/government/uploads/system/uploads/ attachment_data/file/348617/ Hosp_food_panel_report.pdf Vitamin D: An overview of vitamin D status and intake in Europe A review: ‘Vitamin D: An overview of vitamin D status and intake in Europe’ has just been published online in the British Nutrition Foundation journal Nutrition Bulletin. Using evidence from surveys and studies across Europe, the review reports on the prevalence of low vitamin D intakes and inadequate vitamin D status both in general and vulnerable population groups. It further discusses some of the measures used to improve vitamin D intake. http://onlinelibrary.wiley.com/ doi/10.1111/nbu.12108/abstract Variation in dementia care The Care Quality Commission has published ‘Cracks in the pathway’ reviewing the care people living
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with dementia receive as they move between care homes and acute hospitals. Inspectors from the Commission visited 129 care homes and 20 hospitals across England, during 2013 and 2014 and found overall more good care than poor care. But the quality of care for people living with dementia varies greatly. www. cqc.org.uk/content/variationquality-care-means-people-livingdementia-risk-receiving-poor-care Dementia ‘amBaSSaDorS’ NHS England has announced that seven dementia ambassadors are beginning to spread the word about the importance of diagnosing more patients with dementia in a bid to help improve patients’ and their carers’ quality of life. The seven, who are based around the country, will be helping local GPs in England to use the best possible methods to diagnose more people. Their focus is to support CCGs to improve the numbers of people able to access a timely diagnosis of dementia and appropriate care. Their work will include providing one to one support to CCGs, sharing learning and best practice, providing tools, resources and guidance. www.england.nhs.uk/2014/10/13/ ambassadors/
Evidence update: Preventing Type 2 diabetes: population and community-level interventions NICE has published a new evidence update Preventing type 2 diabetes: population and community-level
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interventions (Evidence update 66). It is a summary of selected new evidence relevant to NICE public health guidance 35 ‘Preventing Type 2 diabetes: population and community-level interventions’ (2011). Evidence updates are intended to increase awareness of new evidence they do not replace current NICE guidance and do not provide formal practice. www.evidence.nhs. uk/about-evidence-services/bulletins-and-alerts/evidence-updates/ evidence-updates-by-date HoW HealtHY are We? The Kings Fund has published ‘How healthy are we? A high level guide’. This report provides upto-date high-level information on the state and drivers of England’s health. It includes basic facts on the health of people in England (and sometimes the UK or devolved countries), the main drivers of health, how it varies and is expressed in inequalities, and relevant comparisons with other countries. This is an updated guide incorporating new data and studies. www. kingsfund.org.uk/sites/files/kf/ how-healthy-are-we-oct-2014.pdf
Physical activity, sport and obesity programmes guidance tools Public Health England has published Guide to online tools for valuing physical activity, sport and obesity programmes. This guide summarises a number of online tools that help the user to perform calculations to make the
web watch case for investment in the promotion of physical activity and/or the prevention of obesity. It provides advice on which tool to use in which situation. The briefing will be useful to local authority practitioners wishing to make an assessment of health benefits in order to guide planning and investment decisions. This is likely to include health and social care professionals; sport and physical activity providers and planners; and transport professionals. www. noo.org.uk/visualisation Public health advice: picking mushrooms Public Health England has published advice to the public to take care when collecting wild mushrooms. Each year dozens of people seek medical advice after picking and eating wild mushrooms because some varieties which grow wild in the UK are poisonous and can make foragers ill when consumed: some types can be fatal. Foragers should remember that the poisons in some of the most dangerous wild mushrooms are generally not destroyed by cooking. So far this year the National Poisons Information Service has been consulted for advice on 84 cases. www.gov.
uk/government/news/take-carewhen-picking-mushrooms-poisonsexperts-warn national DiaBeteS auDit The 10th report from the National Diabetes Audit has been published. National Diabetes Audit - 20122013: Report 1, care processes and treatment targets shows that diabetes patients aged under 40 receive fewer vital checks and less often hit treatment targets than older age groups. The report presents findings for the care of over two million people in England and Wales with diabetes, examining key care processes and treatment target achievement rates from 2012-2013. A second report from the audit will be published later in the year; this report will look at the complications of diabetes and mortality. www.hscic.gov.uk/ catalogue/PUB14970 Allied health professionals: quality of care The Health Foundation has published: ‘Focus on Allied health professionals: can we measure quality of care?’ This QualityWatch report, published in partnership with the Nuffield Trust, explores
how best the quality of care delivered by allied health professionals can be measured, and presents the key findings from the available data. The report aims to provide an independent picture of the quality of care, and is designed to help those working in health and social care to identify priority areas for improvement. www.health.org. uk/publications/focus-on-alliedhealth-professionals/ CHilD oral HealtH SurVeY Public Health England has published the first national survey of oral health of three-year-old children in England. It showed that there was a variation of tooth decay prevalence ranging from two percent to 34 percent across the country. However, the large majority of children (88 percent) in this age group have no decay at all. This reflects trends of significant improvements in dental health since the introduction of fluoride toothpaste in 1976. The survey found that found that those children affected had an average of three decayed teeth due to the disease. www.gov.uk/ government/news/new-phe-survey-finds-12-of-3-year-olds-havetooth-decay
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SPECIALIST BARIATRIC DIETITIAN - THE HOSPITAL GROUP The Hospital Group is the UK’s leading private provider of bariatric (obesity) surgery, providing gastric balloon, gastric band, sleeve gastrectomy and gastric bypass surgery. We have a fantastic full-time opportunity for a qualified Dietitian to join our professional and enthusiastic team of clinical and non-clinical staff at our Leeds, Liverpool, Sheffield or Cambridge Clinic (with possible travel to other clinics nationwide). Salary: £21,600 per annum, increasing to £22,000 following successful completion of six-month probationary period. A further increase to £23,000 will occur following successful completion of a further 12 months with the company. Position: Permanent. Hours: 37.5 hours per week, to include some evening and weekend work. The role will mainly involve conducting telephone and face-toface consultations with pre- and post-op bariatric patients. Please call the HR Department on 0121 445 0241 or email hr@thehospitalgroup.org with your CV. Oncology Dietitian - Essex NHS Band 6 Oncology Dietitian required for Essex NHS hospital from 1st to 17th December. 21 hours a week, preferable Monday, Tuesday and Wednesday and there may be a possibility for full time with two days in medicines management. The role covers radiotherapy, chemotherapy and ward work. Experience with nutrition support is essential, smart car user preferable. To be considered for this role, please email hayley@eliterec.com or call 01277 849 649. www.elitedietitians.com Community Dietitian - Kent NHS Band 6 Community Dietitian required for Kent NHS Trust, starting in November. Applicants must have community experience and have their own transport. Excellent rates offered for the right dietitian. Please call 01277 846 946 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com
Part-Time Community Dietitian Band 6 part-time Community Dietitian required in the Midlands starting December for an ongoing role, covering home visits and nursing homes. For this or other dietetic vacancies with Elite, please contact Hayley on 01277 849 649 or email your CV and interest to hayley@eliterec.com www.elitedietitians. com Band 7 Dietitian - London Part-Time Band 7 part-time Dietitian required for London NHS hospital, covering ITU, surgical and gastro for two months starting December. To be considered for this role, please email Hayley@eliterec.com or call 01277 849 649. www.elitedietitians.com Project Role Band 5/6 Midlands Band 5/6 Project Role located in the Midlands which is starting mid-November for five months, training staff on Must and nutritional support. Excellent rates offered for the right Dietitian. Please call 01277 846 946 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com Catering Dietitian Catering Dietitian required for a commercial company to provide nutritional expertise and dietetic advice to catering departments across a range of contracts within healthcare. Starting November/December. Excellent rates offered for the right dietitian. Please call 01277 846 946 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com Clinical Paediatric Dietitian Belfast Band 6 Clinical Paediatric Dietitian required for hospital in Belfast. Must have paediatric experience, starting asap for three months. To be considered for this role, please email Hayley@eliterec.com or call 01277 849 649. www.elitedietitians.com NHDmag.com November 2014 - Issue 99
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CAREER Band 7 Paediatric Dietitian Must have experience dealing with following patient groups aged 0-17 plus outpatient clinics and medical inpatient experience including oncology, gastroenterology, eating disorders (acute managment only), faltering growth, feeding in neurodisability. Experience in dealing with safeguarding and child protection issues essential. For this and similar jobs, please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to registration@pjlocums.co.uk
Paediatric Dietitan - East Sussex We are looking for a Band 7 Dietitian with extensive paediatric experience to help cover clinics and inpatients as part of our Paediatric Dietetic Team at East Sussex. If you are interested please let me know the CV with clear indication of their paediatric experience. For this and similar jobs please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to registration@pjlocums.co.uk.
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events and courses Food Matters Live Nutrition Society Winter Meeting 2014 Organised jointly with the Royal Society of Medicine Nutrition and age-related muscle loss, sarcopenia and cachexia’ 9-10 December 2014 Royal Society of Medicine, London, UK www.nutritionsociety.org/winter-meeting-2014 The meeting will explore the importance of nutrition in preventing and treating sarcopenia and cachexia. Attendees will learn about current research and clinical perspectives on the impact of skeletal muscle on human health, and how nutrition influences this. They will have the opportunity to network with colleagues from basic science, nutrition, dietetics, public health and industry. The programme will include a variety of plenary sessions, Original Communications, the Cuthbertson Medal Lecture and opportunities for networking.
New Frontiers in Fibre - British Nutrition Foundation half-day symposium 29th January 2015 - 12.30 to 16.30 Governors Hall, St Thomas’ Hospital, London SE1 7EH This insightful half-day event will explore the relationship between fibre and health and will include individual presentations by experts in the field followed by a facilitated Q&A panel discussion. The symposium will look at emerging research on the role of fibre and novel fibres in mineral absorption, immunity, cardiovascular disease and obesity. It will also cover the implications of increasing fibre in the diet generally and in certain clinical groups. Full programme details and booking information can be found at www. nutrition.org.uk/bnfevents/events/new-frontiers-in-fibre
University of Nottingham - School of Biosciences Modules for Dietitians and other Healthcare Professionals • Paediatric Nutrition - 16th April 2015 • Nutrition Support - 22nd April 2015 For further details please email marie.e.coombes@ nottingham.ac.uk, tel: 0115 951 6238 or check out the University website at www.nottingham.ac.uk/biosciences and click on short courses then ‘for practising dietitians’.
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NHDmag.com November 2014 - Issue 99
18th to 20th November ExCeL, London www.foodmatterslive.com
Improving Patient Care Conference 25th November The Mermaid, London www.improving-patient-care.co.uk/event-home
Vygon Gastrostomy Study Days
27th November Vygon organises a number of study days around the country targeted specifically at healthcare workers who provide gastrostomy care. Leeds (The Village Hotel, Leeds South) www.vygon.co.uk/training/studydays
Obesity- A National Epidemic
8th December Conference The Mermaid Conference & Events Centre, London http://obesity-conference.govtoday.co.uk/programme
Early Years: High Impacts for Health 9th December The Mermaid Conference & Events Centre, London www.infanthealthconference.co.uk/programme
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the final helping
Neil Donnelly
I had a plan, or maybe more appropriately, I had planned this Final Helping to discuss the rise and rise of ‘Gluten Free’. This followed a request to have a chat with a friend who presented with ‘non-coeliac gluten sensitivity’. I have, however, decided to put this issue on hold at the last minute following the recently published 35-page report by the Chief Executive of NHS England, Simon Stevens. I would like to coin a well-known phrase… ‘Simon says’, “Lose weight, stop smoking, do more exercise and take more responsibility for your own health.” He urged employers to offer cash prizes or vouchers to help staff lose weight to tackle obesity. Is that really the best we can do?
. . . as we draw closer to an election next year, let’s do a Nigel Farage (UKIP) and formalise UKOP (United Kingdom Obesity Party) . . .
Neil is a Fellow of the BDA and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders
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This obesity epidemic started some three decades ago and successive governments steadfastly refused to recognise the oncoming tsunami, thinking it was just a bow wave and, by the time it reached shore, you would be able to paddle in its wake, albeit with the help of some totally unrealistic government targets of course. Numerous weighty reports later and now, with nearly two thirds of the population either overweight or obese, we are still no nearer to producing anything that the overwhelming majority beneficiary of NHS budget expenditure can
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engage with. Sorry, but I think this is now unacceptable. Well, I have another plan. With ‘Save our NHS’ likely to be leading the debate as we draw closer to an election next year, let’s do a Nigel Farage (UKIP) and formalise UKOP (United Kingdom Obesity Party), and with the support of experts in the field, well known and respected celebrities, one in 10 obese adults, disenchanted voters and social media, come and ‘Save our NHS’ from being plunged into dealing with obesity-related illnesses and disorders until it is bankrupt and beyond recognition. Yes, I know what you’re thinking, what is he on about? Has he lost the plot? Well, let’s imagine… if one obese adult lost just one pound a week for 24 weeks and kept it off for a year, would that make a difference to the ‘overstretched’ NHS? How about just one in 10 of the obese population, that’s one and a quarter million individuals? You bet it would. Play your part. Get involved. Next time… The Big Weigh In Master Plan: get elected! Join the Party…. Register your interest to the Editor marked UKOP!