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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals
NHDmag.com
October 2016: Issue 118
AUTISM:
Causes & implications of excessive food selectivity LOW CARB DIETS OBESITY MANAGEMENT TYROSINAEMIA TYPE I AND II IODINE DEFICIENCY
DYSPHAGIA Pages 29 to 36
Neocate: The UK’s No. 1 Amino Acid-Based Formula References: 1. De Boissieu D, Matarazzo P, Dupont C. J Pediatr 1997; 131(5):744-747. 2. Vanderhoof JA, Murray MD, Kaufman S et al. J Pediatr 1997; 131 (5):741-744. 3. Koletzko S, Niggemann B, Arato A, et al. J Pediatr Gastroenterol Nutr 2012; 55(2):221-229. 4. Venter C, Brown T, Shah N, et al. Clinical and Translational Allergy 2013; 3(1):23. 5. Ludman S, Shah N, Fox A. BMJ 2013; 347-355. 6. Fiocchi A, Brozek J, Schßnemann H, et al. WAO J 2010; 3:57-161. 7. Hill DJ, Murch SH, Rafferty K et al. Clin Exp Allergy 2007; 37(6):808-822. Neocate is a Food for Special Medical Purposes for use under medical supervision, after consideration of all feeding options including breastfeeding. eHF=Extensively Hydrolysed Formula; AAF=Amino Acid-Based Formula; GI= Gastro Intestinal
FROM THE EDITOR
WELCOME Emma Coates Editor
As the leaves start to become golden and red and you pull out your woolly jumpers and scarves for the first time, NHD brings you a warm, nutritional hug as the nights draw in. We’re just too good to you, I know!
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.
I’ve thoroughly enjoyed reading through this issue whilst we have prepared it for all of you. As always, we love to share a diverse range of articles from fantastic contributors, giving you the latest insights and recommendations for your practice, and this month is no exception. In return, can I take a few minutes of your time? I have a few questions for you. What counselling theories do you currently use in your obesity management strategy? Claire Chaudhry, Freelance Sports Dietitian, takes us through typical practice, Transactional Analysis and Rational Emotive Behaviour Therapy, highlighting their potential benefits when tailoring your approach. Ever thought about autism and its impact on dietary intake? Most commonly addressed in paediatrics, autism can have a huge impact on dietary intake and nutritional status. Our Cover Story by Darran Tunnah, Secondary School SENCo in Shrewsbury, sheds light on the excessive food selectivity which occurs in this challenging and fascinating patient group. Do restricted diets have an impact on iodine levels? Rachel Wood, Specialist Paediatric Allergy Dietitian, Royal Manchester Children’s Hospital, presents an interesting article discussing the risks of iodine deficiency in restrictive diets. She explores current recommendations and shares some of her clinical experience in this area, whilst managing her paediatric allergy caseload. Dysphagia: what more can you learn? Well, we have an update on current products available and a most interesting
case study by Victoria Williams RD, involving a motor neurone disease patient and the dietetic management of his dysphagia. We never stop learning! Veganism: healthy or not? It has become more popular as a dietary choice over the last 10 years, possibly driven by research and celebrity endorsement, with the likes of Jennifer Lopez, UK singer Ellie Goulding and even with music royalty such as Beyoncé and Jay-Z reportedly giving plant-based diets a go. The Vegan Society reported results of a poll, earlier this year, which revealed that over half a million people in the UK are now choosing a vegan diet. We asked Charlotte Sterling-Reed, Registered Nutritionist, to take a closer look at this growing dietary trend, focusing on how to achieve a balanced vegan diet and where it all fits into healthy eating. I think that’s enough questions for now! But our October articles continue: IMD Watch is brought to you by Suzanne Ford, Adult Metabolic Dietitian who shares her knowledge and experience of the dietary management of Tyrosinaemia Type I and II. We are also pleased to introduce Aoife Hanna, Freelance Dietitian and founder of Eat Right Ireland. She brings us her first NHD article, which discusses the controversial use of low carbohydrate diets in Type 1 diabetes. Aoife takes us through the evidence surrounding their use. And be sure to visit our subscriber zone on our website to access more great articles via NHD Extra - www.NHDmag.com. So, thinking about answers to all of those questions was definitely worth it, wasn’t it? Emma www.NHDmag.com October 2016 - Issue 118
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CONTENTS
13 COVER STORY Autism and excessive food selection
6
News
42 VEGAN DIET: How healthy is it?
Latest industry and product updates
9 OBESITY MANAGEMENT Counselling theories
45 On behalf of PENG Clinical Update Course 47 Web watch Online resources
17 Iodine deficiency Restrictive diets 21 IMD watch Tyrosinaemia Type I and Type II
29-36 DYSPHAGIA 30 Product listing 33 Motor Neurone Disease 38 Low carb diets Type 1 diabetes: are they suitable?
and updates
48 Book review Obesity: The Biography
Copies to give away
50 Events & courses, dieteticJOBS Dates for your diary and
job opportunities
51 The final helping The last word from Neil Donnelly
Copyright 2016. All rights reserved. NH Publishing Ltd. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.
Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst
4
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
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www.NHDmag.com October 2016 - Issue 118
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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.
UK Obesity ‘Plan for Action’ Well, the much awaited Obesity Plan1 has now been published, resulting in real disappointment across the board. The Plan for Action sets out to focus on two main areas within the next 10 years, by encouraging: 1. Industry to cut the amount of sugar in food and drinks and 2. Primary school children to eat more healthily and stay active. Unfortunately, as we are well aware, obesity will only truly be solved by taking ‘multi-faceted’ approaches across the life-course. For example, many infants are born overweight due to high rates of maternal obesity and rising rates of gestational diabetes. In fact, healthcare costs are 72% higher amongst infants born to obese mothers compared with those born to healthy weight mums.2 A little down the line, lack of education about appropriate weaning and feeding of toddlers seems to be contributing to the commonly quoted statistic that ‘a third of children aged two to 15 are overweight or obese’.3 So, whilst sugar may be one factor contributing to obesity, we can see that there are other causes. We also need to consider the sheer volume of unhealthy foods surrounding children today - the forces of so many temptations. Whilst parents have an important role in influencing children, so do their friends, with friends’ junk food habits appearing to have a stronger influence than parents’ encouragement to eat healthily.4 Education is also important as children need to understand about why healthy eating is important for benefits to embed to a deeper level - an aspect overlooked in the report. Interestingly, whilst there is mention of a soft drinks levy, the simplicity of encouraging children to drink water appears to go unmentioned. The 13-page report also fails to refer to the World Health Organisation (2016) End to Obesity Report.5 This is a brilliant report; a real ‘gold-standard’ in terms of what we should be striving for. Given that we usually look to the World Health Organisation’s guidance, in this instance, it was most disappointing to see that much of its excellent context was not utilised. So, where to go from here? Well, clearly there is scope to write to the Secretary of State for Public Health and Innovation to identify the shortcomings of this report. Otherwise, it seems that it’s up to us to drive ideas forward, ideally targeting the actions justifiably put forward by the World Health Organisation. References 1 HM Government (2016). Childhood Obesity: A Plan for Action. Available at: www.gov.uk/government/publications/ childhood-obesity-a-plan-for-action 2 Morgan KL et al (2015). Obesity in pregnancy: infant health service utilisation and costs on the NHS. BMJ Open 5(11): e008357 3 Health and Social Care Information Centre (2009). Children’s overweight and obesity prevalence, by survey year, age-group and sex www.ic.nhs.uk/webfiles/publications/HSE/Health_Survey_for_England_1995_ to_1997_Revised_Childrens%20 Table%204.xls 4 Guidetti M et al (2012). The transmission of attitudes towards food: twofold specificity of similarities with parents and friends. Br J Health Psychol 17(2):346-61 5 World Health Organisation (2016). Report of The Commission on Ending Childhood Obesity. Available at: http://apps.who.int/ iris/bitstream/10665/204176/1/9789241510066_eng.pdf
For more news and additional articles see NHD Extra online: www.NHDmag.com 6
www.NHDmag.com October 2016 - Issue 118
NEWS VITAMIN D ENHANCED EGGS One way to top up dietary vitamin D intakes could be to eat vitamin D-enriched eggs. Now, pioneering research has tested whether eating these eggs could help to improve vitamin D status. An eight-week randomised-controlled trial was carried out on 55 healthy adults aged 45 to 70 years. Participants either ate ≤2 eggs per week (the control group; vitamin D status was expected to decline), or seven vitamin D3 or 25(OH)D3 enhanced eggs per week. Results showed that vitamin D status was 7-8nmol/L lower in the control compared with the vitamin-D enhanced eggs. Vitamin D status also declined significantly in the control group during the winter, but was sustained in the vitamin-D enriched egg groups. These innovative findings suggest that eating seven vitamin-D enhanced eggs a week could help to improve vitamin D status and help to sustain this during the winter months. For more information, see: Hayes A et al (2016). American Journal of
PRODUCT / INDUSTRY NEWS WILTSHIRE FARM FOODS HEALTHY BALANCE RANGE It’s normal to lose bone density as we age, but increasing vitamin D and calcium intake can help reduce these effects and encourage maintaining bone health. Each meal in Wiltshire Farm Foods’ new Healthy Balance range has been fortified with enough calcium and vitamin D to provide at least 70% of the new SACN guidelines of 10μg a day. Visit wiltshirefarmfoods.com for more details. Lo
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DIGES T HEALTH nals NETW ORK The Magazine October
for Dietitians,
2016: Issue
Nutritionis
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NHDmag.
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AUTISM:
of implications ty ctivi Causes & e food sele excessiv LOW CARB
DIETS
ENT MANAGEM OBESITY I AND II EMIA TYPE TYROSINA CY IODINE DEFICIEN
DYSPHAGIA to 36 Pages 29
Clinical Nutrition [Epub ahead of print].
NEW VITAMIN D RECOMMENDATIONS The much anticipated vitamin D recommendations have now been published by the Scientific Advisory Committee on Nutrition. In a nutshell, everyone aged one year and above should be aiming for a daily vitamin D intake of 10 micrograms. However, whether we strive to obtain this via dietary sources, or take a supplement, varies according to age, season and degree of skin pigmentation. The main overarching recommendations are shown in Figure 1. Within these overarching guidelines, there are a number of specific recommendations. These include that breastfed babies (partially or exclusively breastfed) should be given a daily supplement (typically ‘drops’) containing 8.5 to10 micrograms vitamin D from birth up to one year of age. Formula-fed babies needn’t take vitamin D supplements unless they are receiving less than 500mls (about a pint) of formula a day, as these tend to be fortified with vitamin D. For children aged one to four years, a daily supplement containing 10 micrograms vitamin D is recommended. Equally, for those aged five years and older, including pregnant and
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Figure 1: UK vitamin D recommendations (SACN, 2016) From birth up to 1 year of age
A vitamin D intake in the range of 8.5 to 10 micrograms/day is recommended, including those of are exclusively or partially breast fed.*
Ages 1 year and above
A vitamin D intake of 10 micrograms/ day is recommended, including pregnant and lactating women and population groups at risk of vitamin D deficiency (those with minimal sun exposure or from ethnic minority groups with dark skin).
*Precautionary recommendation due to insecurities in the data.
breastfeeding women, a daily supplement containing 10 micrograms of vitamin D is advised from October to March when sunshine exposure is limited. All year-round supplementation with 10 micrograms vitamin D daily is advised for people who rarely go outdoors, such as frail or housebound individuals. Those with dark skin, or who habitually wear clothes that cover most of their skin while outdoors have also been guided to supplement.
For more information, see: SACN (2016). Vitamin D and Health Report. Available at: www.gov.uk/government/publications/sacn-vitamind-and-health-report. www.NHDmag.com October 2016 - Issue 118
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BREASTFEEDING IS BEST FOR BABIES
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Discover more at hipp4hcps.co.uk 1 Contains 1.89g/100kcal of protein, including α-lactalbumin, making the protein level and quality closer to that found in breastmilk (1.7g/100kcal). Nommsen LA et al. Am J Clin Nutr 1991; 53: 457–465. 2 Koletzko B et al. Am J Clin Nutr 2009; 89(5):1502S–8S. 3 Price per 100g of infant milk powder: HiPP £1.06, Aptamil £1.11. Price per case of 24 infant milk hospital formula: HiPP £8.36, Aptamil £8.84. Prices correct as of May 2016. Important Notice: Breastfeeding is best for babies. Breastmilk provides babies with the best source of nourishment. Infant formula milks and follow on milks are intended to be used when babies cannot be breastfed. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle feeding may reduce breastmilk supply. The financial benefits of breastfeeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Infant formula and follow on milks should be used only on the advice of a healthcare professional.
WEIGHT MANAGEMENT
COUNSELLING THEORIES AND OBESITY MANAGEMENT Claire Chaudhry Community NHS Dietitian/Private Sports Dietitian BCUHB/Claire Sports Nutrition Consultancy
Obesity in the UK is currently the biggest public health concern and addressing obesity is the responsibility of all healthcare professionals.2 The UK has the highest rate of obesity compared with other European countries and costs the UK economy £47 billion pounds a year.3 There are a number of genetic, medical, social and psychological factors that contribute to obesity and counselling theories can help with understanding psychological factors.
In Claire’s 14 years of experience she has worked in acute and community NHS settings and has taught Nutrition topics at universities and colleges and regularly provides talks to groups, NHS and for the private sector. Her dissertation at university was ‘Eating behaviours in students’, leading her to undertake a Certificate in Counselling in 2014 accredited by the BACP.1
Counselling involves working with individuals or groups of people who may be in crisis and/or who require support, guidance or problem solving. The task of counselling is giving the ‘client’ the opportunity to explore and discover new ways of living their life to the full. Counselling in obesity management provides: • insight into understanding the origins of the behaviour, leading to more of a rational control over feelings and eating behaviours; • self-awareness, with the client becoming more aware of thoughts or feelings about food; • self-acceptance, developing a positive attitude towards themselves, whatever size or shape; • problem solving, finding a solution to a problem which the client hasn’t been able to resolve in the past; • behaviour change, which is vital with regards to changing eating behaviours for the benefit of the client; • empowerment, working on skills and knowledge to help the client achieve empowerment and confidence, hoping to tackle coping mechanisms, i.e. binge eating; • restitution to help the client to make amends for previous mistakes or previous attempts at behaviour changes.4
For full article references please email info@ networkhealth group.co.uk
THE CURRENT APPROACH
There are many theories in counselling that can help provide further under-
standing of the psychological aspects of obesity. Cognitive behaviour therapy (CBT), developed in the 60s by American psychiatrist Aaron Beck (1921), has shown to be evidenced based and works in obesity management. CBT involves practical solutions based on the individual client’s requirements and dietary goals, e.g. always taking a shopping list to the shops, not snacking in between meals etc. CBT has to be revisited regularly for behaviour change to be maintained.5 As dietitians, we take the patientcentred therapy (PCT) approach with all clients, based on Carl Rogers (19021987). PCT must encompass three basic core conditions for a beneficial relationship to occur. Creating a comfortable, non-judgemental environment by demonstrating; congruence (genuineness), empathy and unconditional positive regard (respect) for their client.6 The most recent theory to emerge in obesity management is mindfulness, which is based on Gestalt therapy by Fritz Perls (1893-1970). Gestalt therapy looks at the healthy functioning adult and keeping in touch with oneself. Goals for Gestalt therapy are heightened awareness and ‘being mindful’; yoga can also be termed as a form of Gestalt therapy. An article in Dietetics Today (January 2016) shows results from a mindfulness course of five sessions in a group, which found that clients attending said they were paying more attention to how they relate to food and www.NHDmag.com October 2016 - Issue 118
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• Adult: a state of the ego which is making logical predictions and decisions about major emotions affecting development. While a person is in the Adult ego state, he/she is directed towards an objective, they are rational, calm and logical, e.g. talking and laughing with a close friend/ partner is an adult-to-adult transaction. The aim of TA is to strengthen this adult ego. • Child: a state in which people behave, feel and think similarly to how they did in childhood, e.g. a person who receives a poor evaluation at work may respond by comfort eating, as if shouted at as a child, or rewarding them with food if they receive a good evaluation from their employer. found this approach more understanding and compassionate.7 There are other theories that can prove useful in obesity management and can enable the dietitian to understand more about the client’s beliefs and behaviours surrounding food. The two to discuss further are Transactional analysis by Eric Berne (1910-1970) and Rational Emotive Behaviour Therapy (REBT) by Albert Ellis (1913-2007). Transactional Analysis (TA) by Eric Berne This looks at the transactions (relationships) that have taken place or are taking place between the Parent, Adult and Child ego states. This involves understanding each of our ego states and their transactions in our ‘life scripts’. At any given time, at work, at home with your partner or children, every adult experiences and manifests his or her personality through a mixture of behaviours, thoughts, and feelings. The aim of TA is learning to strengthen the adult in all relationships/transactions and to be aware of the child and parent influences. • Parent: a state in which people behave, feel and think in response to an unconscious mimicking of how their parents (or other parental figures) acted, or how they interpreted their parent’s actions, e.g. a client may influence their children’s eating habits by telling their child to finish what is on your plate (despite fullness in the child) as this was demonstrated in their own childhood; therefore, they are taking on the parent script. 10
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Here are examples of statements related to TA that have been said during consultations: “My husband is always on at me to lose weight and he says that I can’t have that food or this food, so then I hide what I am eating so he can’t see me, when he does find out he gets frustrated and shouts.” In this instance the client is in a Child ego and her husband has taken the part of the Parent ego. “My mum used to reward me with chocolate if I had been a good girl; I still do that now, reward myself with food, when I have been ‘good’!” This client is in the Child ego and is repeating her positive childhood script from her parent. “We were punished at school for not finishing our food off our plate, I make sure I never leave anything on my plate now.” This client is in the Child ego and is repeating negative memories from their childhood script. Using the knowledge of TA in dietetic consultations will enable dietitians to understand how the person’s eating behaviours and the emotions associated with them, have developed and also offers guidance on how best to question their client’s beliefs. It is the goal of TA that the adult in obesity management is aware of their Child state when it comes to their eating behaviours. Unhealthy childhood experiences can lead to the client being pathologically fixated in the Child and Parent ego states, bringing discomfort to an individual and/or others in a variety of forms, including mental illness, binge eating and other eating disorders.8 Often ‘childhood scripts’ surrounding food continue within the family from
WEIGHT MANAGEMENT generation to generation, contributing to obesity throughout the family tree. REBT by Albert Ellis Dr Ellis explains that any irrational beliefs we have lead to negative feelings, which also leads to actions that can be self-defeating. The aim of this theory involves disputing the client’s irrational beliefs and replacing them with rational beliefs. Irrational beliefs in obesity clients can be: • biological, e.g. resistance to change becomes ingrained in the eating habits of the whole family; • emotional, e.g. they fail to see how upset they are and can often deny, or try to hide, or ignore their feelings with comfort eating; • insufficient scientific reason, e.g. not seeing the bigger picture of their eating behaviours and health consequences; • unrealistic beliefs about change, e.g. expectations of themselves such as losing five pounds every week; • focusing on their past failures, as this will only reinforce irrational beliefs and lead to them being unsuccessful in their dietary goals. Here are examples of statements related to REBT that have been said during consultations in obesity management: “By going off my diet when I go out for an evening proves I cannot stick to it.” “I must be perfectly thin for me to be successful, if not, I am a terrible person.” “I cannot possibly say no to someone who has offered me food, what would they say?” “I have to lose weight; I look disgusting to everyone!” The aims of REBT in aiding with obesity management: • Dispute irrational beliefs, why? What is the reasoning behind this thought? • Dispute the terribleness of the situation; is it really terrible, awful, horrendous or even catastrophic that you have put one pound on in weight? • Dispute self-hatred, learning to love you, flaws and all. • Dispute seeing things as black and white, e.g. there are no good and bad foods only good and bad diets.
• Helping to use coping statements and changing expectations of the client: “It is certainly not bad that I haven’t lost two pounds this week. I am happy with one pound weight loss this week.” REBT states that one of the changeable reasons to help with obesity management is that clients hold unrealistic and inflexible expectations about their weight and eating behaviour. REBT can help with being more tolerant, more accepting, more understanding of human fallibility and being rational about eating behaviours which can help with tackling obesity.9 CONCLUSION
As dietitians, our knowledge is based on scientific evidence and practical dietary advice to help aid weight loss in obesity management. Counselling in Dietetics is covered in our degree. However, there is more to learn regarding the counselling theories and the practicality of using them in a clinic or group setting in obesity management. We require to be aware of our own limitations as healthcare professionals and we are not trained counsellors. We need to ensure that we are able to signpost our clients to other departments, e.g. psychologist, psychiatrist, or mental health team when required. Other limitations regarding the counselling theories include that they are not to be used in isolation with clients; very rarely does ‘one size fit all’; we know through evidence that obesity management within the NHS setting can work individually and within group sessions for different clients. The counselling theories require an attitude of a tool bag: which counselling theories better aid your client in their dietary goals depends on their explanation to you of their thoughts, beliefs, and behaviours surrounding food. Further reading Cooper Z, Fairburn C and Hawker D (2003). Cognitive behavioural treatment of obesity, a clinician’s guide. the Guilford press, New York Hunt P and Hillsdon M (1996). Changing eating and exercise behaviours, a handbook for professionals. Blackwell publishing, Oxford Sawkill S et al (2013). A thematic analysis of causes attributed to weight gain: a female slimmer’s perspective. Journal of human Nutrition and Dietetics, Vol 26, issue 1, pg 78-84 Hancock REE, Bonner G, Hollingdale R and Madden AM (2012). ‘If you listen to me properly, I feel good’: a qualitative examination of patient experiences of dietetic consultations. J Hum Nut Diet. 25, pg 275-284 Nash J (2013). Diabesity: What have emotions got to do with it? Diabetes in practice 2, pg 48-56
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