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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com August / September 2016: Issue 117

SIZE MATTERS Health behaviours & body respect

SPECIAL INFANT FORMULAS ONS PRESCRIBING BARIATRIC SURGERY MALNUTRITION

Fatty acids & school performance

Kcal Protein

400 20g Vits & Mins Fibre

50% 0 g RNI

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Date of preparation: 03/16

FROM THE EDITOR

WELCOME . . .

Emma Coates Editor

Emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the NHS. She has recently moved into industry and currently works as Metabolic Dietitian for Dr Schar UK.

This double issue of NHD for August and September is filled with glorious dietetic treats for us all to enjoy whilst hopefully lounging in the sun with a long cool drink. OK, I’m really stretching my imagination here with the British summer having been a bit of a damp squib, but the fantastic articles we have for you this time are definitely real.

Dietetics always promotes healthy lifestyle choices and achieving a healthy weight. We have two great articles this issue, with quite contrasting approaches to these goals. An alternative approach comes from Dr Lucy Aphramor who shares her insights into the ‘Well Now’ way, where health gain and body respect become the focus of therapy in healthy weight services. Our second article on weight management is by Maria Dow, Freelance Dietitian, who discusses the clinical nutritional management of the bariatric patient; explaining surgical options and post-operative care required for this patient group.

Adult metabolic dietitians, Suzanne Ford (North Bristol NHS Trust) and Louise Robertson (University Hospitals Birmingham NHS Foundation Trust), bring this issue’s IMD Watch to us, focusing on Maple Syrup Urine Disease management in the adult patient.

Specialist Dietitian, Maeve Hanan explores a multi-disciplinary approach to malnutrition and we welcome back Rychelle Winstone, Clinical Lead Paediatric Dietitian, with her thorough overview of specialist infant formulas and their use in practice. The handy Reference Table on pages 36-37 is a very useful resource.

Don’t miss too, Dr Carrie Ruxton’s look at fatty acid supplements and school performance, with evidence supporting the role these can play in children’s learning and behaviour. We also feature an article from the BSNA on the prescribing of oral nutritional supplements (ONS) in medical management.

The world of freelance dietetics is a growing area where practice should be safe and evidence based. Freelance Dietitian, Anne Wright provides an ethical discussion about the management of cancer care in freelance practice, where boundaries for safe practice are vital in maintaining safety for both practitioner and patient.

Be sure to visit our Subscriber zone on our website to access more great articles via our digital supplement NHD Extra: www.nhdmag.com.

You’ll find an interesting sports nutrition case study from Helen Phadnis on the dietary management of an experienced climber and some stimulating and curious Food and Drink articles.

Ursula Arens delves into the world of energy drinks and Michelle Sadler gets a taste for crickets, locusts and mealworms, as she discusses the use of insect protein in the diet. Also, ever wondered what a meals on wheels nutritionist gets up to throughout the day? Annabelle de la Bertauche, Registered Nutritionist takes us through a Day in the Life of a Meals on Wheels Nutritionist.

On top of all that, don’t forget our online Student zone. This month we have a great article from Joe Alvarez, University of Chester student, where men in dietetics are discussed. A must read for Guyatitians!

If you are lucky enough to have some time off over the next few weeks, enjoy your summer break and we’ll see you in October for more excellent NHD articles and nuggets of dietetic information. Emma

www.NHDmag.com August / September 2016 - Issue 117

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9 COVER STORY

CONTENTS

Size matters: health gain & body respect with the ‘Well Now’ way 6

News

Latest industry and product updates

15 Bariatric surgery

Procedures and nutritional

management of patients

41 FATTY ACIDS Supplements & school performance 45 ONS prescribing

In disease-related malnutrition

21 IMD WATCH

49 Freelance practice

Managing cancer care patients

Maple Syrup Urine Disease

52 Web watch

Online resources and updates

25 Malnutrition

A multi-disciplinary approach

33 SPECIALISED INFANT FORMULA An overview

54 Events & courses, dieteticJOBS

Dates for your diary

& job opportunities

55 The final helping

The last word from Neil Donnelly

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.

Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst

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Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk

@NHDmagazine

Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

www.NHDmag.com August / September 2016 - Issue 117

ISSN 1756-9567 (Print)

NETWORK HEALTH DIGEST

www.NHD mag.com your essential resource •NHD eArticles with CPD •Live health news •dieteticJOBS.co.uk •Events and Courses •Essential links

Subscriber zone

• NHD digital - view the latest issue of Network Health Digest as well as back issues • NHD Extra - our supplement with additional articles for subscribers • NHD at-a-glance library of published articles

Student zone

Introducing our new resources specifically designed for students of Nutrition and Dietetics

A wealth of useful dietetic resources for all dietitians and nutritionists Login with your username and password to view the Subscriber zone.

If you don’t have login details, you can check whether you are eligible for a FREE subscription to Network Health Digest at

wwwNHDmag.com

Make the most of your NHD Community!

NEWS

FOOD FOR THOUGHT

Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd Emma is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health. www.nutritionalinsight.co.uk hello@nutritionalinsight.co.uk

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

We would love to hear from you.

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Brexit - are RCTs the way to go?

Two new papers have been published questioning whether we need more randomised controlled trials (RCTs) within the field of nutrition. At present the number of epidemiological studies heavily outweighs the number of RCTs. One pool of thought is that RCTs often recruit subjects with a history of disease (or an increased disease risk) and have relatively short periods of follow-up. Cohort studies, on the other hand, typically recruit healthy subjects at baseline and have longer periods of follow-up, usually 10 to 15 years. These differences may account for some of the discrepancies we see between the different types of study.

The other pool of thought is that RCTs play a valuable role in helping to identifying ‘non-significant’ findings. Whilst some may think that the outlook of this is rather grim, it is in fact a good thing. Lack of findings can actually help in refuting epidemiological associations that may have been hampered by confounders.

So, which way to go? Personally, I’d say that we need more RCTs that are adequately designed and fall in line with CONSORT (Consolidated Standards of Reporting Trials) guidelines. That way, outcomes can be compared fairly between studies and firmer conclusions drawn.

Also, given the recent Brexit choice, the question is whether collaborative cohorts with European colleagues will still go ahead. Funding sources were challenging enough and certainly won’t become any easier. So, from that viewpoint, perhaps specific well-designed RCTs may be the way to go for now.

For more information, see: Loannidis JPA et al (2016); American Journal of Clinical Nutrition Vol 103, no 6; pg 1385-86 and Temple NJ (2016); British Journal of Nutrition Vol 116, no3; pg 381-89.

CRANBERRY JUICE FOR UTIs? It is often thought that cranberry juice is great for urinary tract infections (UTIs). That said, the evidence for this has never really been substantiated.

Now, a new randomised controlled trial has tested to see if the science really exists.

Women with a history of UTIs (mean age 41 years) were randomly allocated to drink 240ml cranberry juice (n=185), or a placebo

www.NHDmag.com August / September 2016 - Issue 117

(n=188) over a period of 24-weeks. The number of UTI episodes was reported throughout. Study compliance was good and the number of UTI episodes was significantly reduced from 67 to 39 (by nearly half) in the cranberry juice compared with the placebo group.

Overall, these results show that long-term daily consumption (about one glass per day) of cranberry juice may help to reduce the risk of UTIs in women with a history of this condition.

For more information, see: Maki KC et al (2016);

American Journal of Clinical Nutrition Vol 103, no 6; pg 1434-42.

NEWS THE NEED TO ASSESS WATER INTAKES SEPARATELY Water has long been merged in with ‘fluids’ when looking at data from dietary surveys. That said, given the health benefits of drinking water, this ideally needs to be analysed and categorised separately. New work has looked into how water intakes are currently assessed in Europe.

A survey of 10 European countries looking at methods used to assess water intakes found great variability in methods. These ranged from 24-hour recalls, to estimated food diaries and food frequency questionnaires. None of these methods had been validated to specifically assess water and fluid intakes.

These findings highlight the need to devise uniform and validated methods used to assess water and fluid intakes. This would help to aid comparisons made between countries and support future recommendations.

For more information, see: Gandy J et al (2016); British Journal of Nutrition [Epub ahead of print].

MICRONUTRIENT INTAKES IN THE VERY OLD We are an aging population, but past nutrition research hasn’t tended to go beyond the 60 to 65 year age mark. The good news is that researchers from the University of Newcastle have now done this, providing nutrition intake data for the ‘very old’.

Nutrient intakes of 75-year-olds living in the North-East of England taking part in the Newcastle 85+ Study were measured using 24hour recalls. Median vitamin D intakes were 2.0µg, calcium 731mg, magnesium 215mg, iron 8.7mg and selenium 39µg per day indicating shortfalls. Of most concern was that 95% of the population had vitamin D intakes below the UKs Reference Nutrient Intake of 10µg per day.

These are important and much needed findings, emphasising the need for more research in this age group. Further research of this nature is also needed to support the formulation of agespecific dietary recommendations required for this growing age group.

For more information, see: Mendonca N et al (2016); British Journal of Nutrition [Epub ahead of print].

PRODUCT / INDUSTRY NEWS

GLUTEN-FREE BREADS FROM GENERAL DIETARY

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Free from wheat, gluten, milk, eggs, soya, maize and nuts. They also contain vitamins and minerals including calcium and folic acid.

Suitable for vegetarians, vegans and kosher diets. www.generaldietary.com

To book your Company’s product news for the next issue of NHD Magazine call 0845 450 2125 WHAT AGE TO WEAN? While most parents begin weaning their infants at six months, there has been a trend towards early weaning, with the introduction of solids at four months. New research has now looked at how this could affect children’s later eating habits.

Research using data from the Southampton Women’s Survey, looked at what age food was introduced compared with feeding difficulties when the children were three years of age, in 2,389 mother-child pairs. Factors such as breastfeeding, the mother’s BMI, age, education and employment were all accounted for.

Sixty-one percent of mothers/carers had some form of feeding difficulties when their child was aged three years, with children being choosy most common (74%). Children who were given solid foods at six months of age or later were significantly less likely to have feeding problems compared with those given solids at four to six months.

While other studies are needed to reconfirm these results, it seems that holding off from the temptation of early feeding may help children to eat better later on. Next we need to find out why this may be.

For more information: www.mrc.soton.ac.uk/sws/

www.NHDmag.com August / September 2016 - Issue 117

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COVER STORY

THE CASE FOR HEALTH GAIN AND BODY RESPECT IN HEALTHY WEIGHT SERVICES Lucy Aphramor Dietitian, Consultant and trainer, Visiting research fellow University of Chester Lucy Aphramor PhD is committed to bringing compassion and social justice into dietetics’ lifestyle conversation.

She is a founder member of Critical Dietetics and nominated to the BDA roll of honour.

For article references please email info@ networkhealth group.co.uk

An increasing number of dietitians are adopting an approach to nutritional wellbeing that promotes health gain and body respect for all, as an alternative to weight management. This shift in focus characterises an approach known as the ‘Well Now’ way. This article explores the rationale behind Well Now’s innovation and illustrates some of its hallmark features in practise.

Imagine that Jay comes to clinic with newly diagnosed hypertension. We see her again six weeks later, during which time she has made significant changes to her eating and activity behaviours, taken up mindfulness practise and changed jobs. She told us that her BMI when we first met was in the range 3035. She still has no wish to be weighed and we don’t know if her weight has changed or not.

Using the column headings in Figure 1, we can consider how change in behaviours may impact health and whether or not Jay’s weight is reduced.

For instance, we know that diet can influence hypertension regardless of weight loss.1 In fact, improved health behaviours impact wellbeing

independently of weight loss across a range of non-communicable diseases (NCDs), such as heart disease and Type 2 diabetes.

Jay told us that the reason she changed jobs was that she was being bullied and discriminated against.

She feels valued in her new job and team morale is high. But how is this relevant to hypertension? Can respect impact NCDs? There is a vast amount of research showing that how we are treated by society has metabolic consequences.2-5 That is, stress has embodied impact even if health behaviours are unaltered.

In acute stress, cortisol is released and when the stress passes, levels of cortisol and adrenaline return to base line. But,

Figure 1: The Well Now Table for untangling health behaviours, respect, weight and wellbeing

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www.well-founded.org.uk

WEIGHT MANAGEMENT

Figure 2: Theaway Well Now Cycle Take 5

The Well Now way: respecting every body now speaking kindly to myself

lots of factors impact my life

Feel better about yourself, greater sense of wellbeing

I accept myself as I am

Listening to your body and emotions Learning to trust yourself

Improved body confidence encourages active living

Respect and value yourself “I will take care of myself right now"

I will listen to my body, eat well & nourish myself

Eating is enjoyable & self-nurturing

Start to feel more in control & self-confident practice compassion

health and a healthy society is a fair society. Erasing science on the health impact of stigma (including size-ism, racism, etc) means that explanations for and interventions to alter population distributions of health will be incomplete, misleading and ultimately harmful.

Rejecting the pursuit of weight loss is not the same as being against patients losing weight.

Instead, it means seeing weight loss as a secondary outcome rather than a primary goal, or reliable indicator of health. Personal health parameters of dietary quality, HbA1C, blood pressure, fitness, mental wellbeing, eating-disorder symptomology and so on, can measure change.

WEIGHT SCIENCE: ADVERSE EFFECT

What of the final column? In six randomised controlled trials (RCTs), tuning in for a few looking after minutes myself a health-gain approach teaching size acceptance is associated with health enhancement and is not linked with The Well Now Cycle harm.1 A weight-focused approach, however, is robustly associated with all-cause mortality via yo-yo dieting, likely through its inflammatory when someone lives with chronic stress this potential.7 The British Nutrition Foundation homeostatic mechanism gets overwhelmed. notes: ‘‘…a positive association has consistently This work is Open Access, which means you are free to copy, distribute and display the work as long as you clearly attribute the 6 work to the author,athat you do not use thisof workdysregulation for commercial gain in any form whatsoever, and that you in no way alter, Instead, new state is reached been observed between body weight fluctuation transform, or build upon the work without express permission of the author. For any reuse or redistribution, you must make clear tothat others the predisposes licence terms of this work. A Well Now way worksheet. published in February 2016, byand Lucy Aphramor, UK. someone to First inflammation, all-cause mortality and usually…with insulin resistance and arterial damage, all of coronary mortality in particular. This finding is which are linked to NCDs. Thus, the stress of very robust (p 37).’’8 living with stigma has embodied consequences. A minority of patients will lose weight and In other words, stigma is a social determinant of keep it off when dieting. (Note that the same health. This is one reason we need to tackle size people would be expected to lose weight as a and other stigma. secondary outcome of a health-gain approach).

But overall: “one third to two thirds of dieters THE ETHICAL DIETITIAN regain more weight than they lost on their diets.

Using an approach that promotes body respect In addition, the studies do not provide consistent for people of all sizes helps reduce size stigma evidence that dieting results in significant health and address body shame. Untangling weight, improvements, regardless of weight change... behaviours and wellbeing, and talking about The benefits of dieting are simply too small and wider determinants of health, supports this the potential harms of dieting are too large for shift. (Figure 2). A narrow emphasis on weight it to be recommended as a safe and effective control can miss the fact that oppression is a treatment.”9 This citation is from a systematic health hazard; respect is a social determinant of review of RCTs of weight management studies 10

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of two year’s duration, which is the best available evidence in the field. Clearly, it turns on its head the conventional belief that we have a safe, reliable, weight loss intervention. As such, it has urgent ethical significance.

It is only possible to write guidelines that find in favour of weight loss by ignoring this data. NICE (2014),10 for instance, has a scope that does not capture this study. Dietetic research is not immune to misrepresenting weight science.11

Figure 3: The Well Now Way Kindful Eating cycle

WEIGHT SCIENCE: INEFFECTIVENESS

It may sound unbelievable given the tenacity of the ‘eat less, move more’ mantra, but long-term weight loss is not seen even when people adhere to sustained calorie deficit. In the largest study tracking calorie deficit, the Women’s Health Initiative,12 almost 20,000 women reduced calories for over seven years. The experimental group averaged a daily deficit of 360kcals from baseline and increased activity levels. At the end of the study, neither the control arm nor the experimental arm showed significant weight change: setpoint overrides calorie deficit in determining adult weight.

In short, perpetuating out-dated messages about weight loss is unethical and harmful.

Dietitians are well placed to advocate for responsible science and advance the message of health-gain and body respect for all.

KINDFUL EATING

For someone who cannot recall a time when their eating choices weren’t guided by calories, switching focus to health-gain can feel like a leap into the unknown. If they have alternated periods of cognitive restraint with periods of chaotic eating, they may fear that letting go of a weight focus is tantamount to giving up

on themselves. Packing away the scales is not saying, “Eat with abandonment”. Instead, it is offering someone the chance to learn to eat with attunement, to listen to their appetite and use body signals to guide eating choices. The focus on body respect also contains the second message: you are worthy of respect as you are right now. Reminding patients that health gain can arise from behaviour change with or without weight loss and that people of all sizes deserve respect, supports sustained self-care.1 We can identify several steps in helping someone relate differently to food after a lifetime of diet-mentality thinking. First, if someone is distressed because of their eating, we can explore www.NHDmag.com August / September 2016 - Issue 117

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