Network Health Digest - February 2020 by NH Publishing Ltd

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The Magazine for Dietitians, Nutritionists and Healthcare Professionals

SATURATED FAT AND Nutrition HEALTH: support for oncology FRIEND Pages 15-18 OR FOE?

NHDmag.com

February 2020: Issue 151

DIET TRENDS FOR 2020 OBESITY & METABOLISM DIET & FERTILITY GREEN TEA ONS & EATING DISORDERS COMPLEX FEEDING DIFFICULTIES CANCER & KETO

For healthcare professionals only

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

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

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

IMPORTANT NOTICE: Breastfeeding is best for infants and is recommended for as long as possible during infancy. *Not sourced from human milk. 2’-FL HMO: 2’-fucosyllactose human milk oligosaccharide. HMOs are a diverse group of bioactive, non-digestible carbohydrates and the third most abundant solid component of breast milk.7,8 References. 1. Kainonen E, et al. Br J Nutr. 2013;109(11):1962–1970. 2. Walker A. J Pediatr. 2010;156(Suppl 2):S3–S7. 3. Flom JD, Sicherer SH. Nutrients. 2019;11(5):E1051. 4. Oddy WH. Ann Nutr Metab. 2017;70(Suppl 2):26–36. 5. Lifschitz C, Szajewska H. Eur J Pediatr. 2015;174(2): 141–150. 6. Jo J, et al. Mediators Inflamm. 2014;2014:249784. 7. Triantis V, et al. Front Pediatr. 2018;6:190. 8. Castanys-Muñ ñoz E, et al. Adv Nutr. 2016;7(2):323–330. ANUKANI190277h November 2019

UP FRONT The ‘unknown’ can be pretty scary for most of us; sometimes it’s frustrating, other times it’s simply intriguing. There’s a lot we don’t know about the world and people around us, even about ourselves. In 2011, Liam Neeson starred in a film called Unknown, where he plays a professor who wakes up after being in a coma for four days and no one knows who he is, not even his wife! Quite concerning, yet intriguing stuff; but as the film progresses, he learns that not all is what it seems and things unfold as he starts to hunt for answers. I won’t explain further, in case it’s a spoiler for anyone wanting to watch this movie! I’d like to think that all of us reading this won’t ever find ourselves in that sort of predicament, but, whether we like it or not, we spend our lives living in the unknown, thinking about the unknown, or trying to fathom out the unknown. It’s a factor we’re often expected to provide answers to everyday, for example, when patients or clients and/or their family/carers ask questions about their care or goals, which aren’t always clear cut; or when your kids ask impossible questions about the universe or simply ask that dreaded, “But why?”; or even the common questions we ask ourselves in the world of dietetics: “How can I improve this?”, “Is this the best way to do things?”, “Does this really work?”. Sometimes, intuition gives us a feel for the answers, but it is research, audit and tracking trends that really lead us to some of the answers we want or need. Sometimes, however, even these can open up a whole other tin of unknowns. Our work here will never be done, we’ll

always keep learning and striving to find answers. Yes, the unknown can be pretty scary, particularly if you’re talking about horror movie situations, or perhaps thinking about what the impact of Brexit will mean for us! However, in the grand scheme of things, working out the unknown can be a really rewarding challenge. Access and information are key to finding your way through the unknown and in NHD this month, we have a diverse wealth of features where research and evidence are discussed and debated to guide you through some of these unknowns. We’re always happy to share the latest information and evidence with you via our magazine, our website, our social media pages and now via our newest platform, The NHD Blog – a new regular feature you can access via our website and social media pages. One of the unknowns in life that’s driving me nuts right now, is the identity of the celebrities on The Masked Singer! A show I never thought would interest me, which is now a guilty pleasure and really addictive. It’s the most bizarre thing to watch on a Saturday night, but working out the unknown identity of a giant singing glittery octopus has never been more appealing to me. Just goes to show, you learn something new about yourself every day! NHD is here for the learning. Enjoy the read! Emma

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

www.NHDmag.com February 2020 - Issue 151

11 COVER STORY Saturated fat and health 6

News

Diet trends

Latest industry and product updates

Food and drink trends in 2020

38 Fussy eating in toddlers Preventative strategies for parents 42 Social care Technology transforming working lives

15 44 Polycystic ovary syndrome NUTRITION SUPPORT Symptom management FOR ONCOLOGY 47 Oral nutritional support 19 Cancer & Keto

Sip feeds and eating disorders

51 GREEN TEA

Questioning a KD approach

22 Spotlight on . . . Food Active - a healthy

weight charity

26 Obesity and energy metabolism Microbiota's association with body weight

30 DIET, FERTILITY AND IVF

54 F2F Interview with

56 A day in the life of . . . A Diabetes

33 Complex feeding difficulties in children An MDT approach

Pauline Emmett

Specialist Dietitian

58 Events, courses & dieteticJOBS Dates for your diary and job listings 59 Dietitian's life Food and three kids

Copyright 2020. All rights reserved. NH Publishing Ltd. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

Editor Emma Coates RD

Advertising Richard Mair Tel 01342 824073

Publishing Director Julieanne Murray

richard@networkhealthgroup.co.uk

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

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

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www.NHDmag.com February 2020 - Issue 151

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ARE SCHOOL DINNERS HEALTHIER THAN PACKED LUNCHES NOW? In England today, up to 30% of primary school children are overweight or obese, according to the latest data. Back in 2006, the contents of lunchboxes from around 1000 children aged eight to nine years old, from primary schools across England were reviewed by researchers. In 2016, a repeat of this assessment was completed, with a smaller sample of around 300 children.1 The findings from the study show that little has changed in the contents of the lunchboxes over the decade. The most common items still being ham sandwiches on white bread and crisps. The vegetable content of lunchboxes has remained very low. However, some positive changes were identified, with a 10-14% decline in sweets, chocolate and sugary drinks. In addition, the proportion containing none of those unhealthy foods increased from 9% to 16%. The level of some nutrients decreased, including a 35% decline in vitamin C content and an 8% decline in vitamin A and zinc. Overall, the proportion of children's packed lunches that met all School Food Plan standards2 (provision of five healthy food groups with none of three unhealthy groups) increased from 1.1% in 2006 to only 1.6% in 2016. There were limitations to this study in that the participation rate in 2006 was low, but it was even lower in 2016 with only around a third of the number of children taking part in 2016 when compared with 2006. Also, the assessment of the lunchboxes was a snapshot of their contents on a single day, so, whether the contents were typical of the rest of the school year is not known. Whilst this study suggests that there some signs of improvement in the content of children’s lunchboxes, there’s a lot more work to do to align them to health eating guidelines 1 Evans CEL, Melia KE, Rippin HL et al (2020). A repeated cross-sectional survey assessing changes in diet and nutrient quality of English primary school children's packed lunches between 2006 and 2016. BMJ Open. Published online 13th January 2020. 2 School Food Plan (2013). www.schoolfoodplan.com/

THE NHS APP: USERS MORE THAN DOUBLE IN THREE MONTHS The NHS App provides a simple and secure way for people to access a range of NHS services on their smartphone or tablet. Available to download on all iOS and Android devices, the app allows individuals to manage repeat prescriptions, book appointments with a GP surgery, view personal GP medical records and much more. The number of patients using the NHS App has more than doubled since Chief Nurse Ruth May announced the ‘NHS App Ambassadors’ scheme in early September 2019. The number of NHS App registered users now stands at over 220,000 compared with 91,000 at the beginning of September last year. More people than ever before booked NHS appointments digitally, choosing to use this route rather than calling their local surgery. In September, there were 1.4 million GP online service appointment transactions. Since September 2019, the NHS has been undertaking a campaign focused on its own staff, encouraging them to download the app themselves. A toolkit of materials was also created for the use of communications teams across NHS organisations to use in their staff-facing channels. The staff-facing campaign marks the first stage of the NHS promoting the app to patients, with broader public-facing activity set to begin in the coming weeks. Find out more at www.digital.nhs.uk/services/nhs-app 6

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COMMERCIAL WEIGHT MANAGEMENT GROUPS COULD SUPPORT WOMEN TO MANAGE THEIR WEIGHT AFTER GIVING BIRTH Women who were overweight at the start of their pregnancy would welcome support after they have given birth in the form of commercial weight management groups, University of Warwickled research has found. The conclusions come from a feasibility study led by the Warwick Clinical Trials Unit,1 which aimed to assess if commercial weight management groups could help women who were overweight (classed as a BMI of ≥25kg/m2) when they became pregnant to return to a more healthy weight after giving birth. The researchers found that women who attended weight management groups 8 to 16 weeks after giving birth lost slightly more weight (around 3kg) as assessed at 12 months postnatally, than those women not offered access to groups. Those who attended more of the 12 group sessions experienced the greatest weight loss. The researchers argue that this suggests that women could benefit in health terms from attending a commercially available weight management programme post pregnancy, and a larger clinical trial should now be conducted to determine the definitive health and other benefits of such a programme and the cost effectiveness to the health service. Whilst women shouldn’t put pressure on themselves to lose weight after having a baby, we know that retaining weight is associated with poorer long-term health for the mother and often leads to further weight gain in subsequent pregnancies. It is also known to reduce the likelihood of breastfeeding and increases the likelihood of their child being obese. 1 Lifestyle information and commercial weight management groups to support maternal postnatal weight management and positive lifestyle behaviour: the SWAN feasibility randomised controlled trial. Published in BJOG: An International Journal of Obstetrics & Gynaecology. DOI: 10.1111/1471-0528.16043

COCHRANE REVIEW: DIET AND PHYSICAL ACTIVITY INTERVENTIONS FOR CHILDREN Parents and other adult caregivers have an essential role in shaping children's health habits by controlling availability of and access to healthy foods and by providing opportunities to be active. Their role is important too, in supporting, encouraging and role-modelling healthy behaviours, whilst adopting supportive feeding styles and practices. However, a recent Cochrane review1 suggests that adding a parent or caregiver component to dietary behaviour change interventions or physical activity interventions may make little or no difference to a child’s dietary intake or physical activity level. Twenty-three studies were found, published between 1982 and 2019, which implemented diet interventions, physical activity interventions, or combined diet and physical activity interventions with children or adolescents, and evaluated the effects of adding an intervention component involving parents or other adult caregivers. Approximately 12,192 children aged 2-18 years were examined. More than half of studies took place in North America, and all but two were conducted in high-income countries. Most studies were school-based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. Whilst the findings found little or no difference as mentioned above, the review did conclude, however, that such interventions probably slightly reduces children's sugar-sweetened beverage intake. Overall, the evidence from the studies reviewed is of low or very low quality, which means that the researchers are uncertain about study results. 1 Morgan EH, Schoonees A, Sriram U, Faure M, Seguin-Fowler RA (2020). Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors. Cochrane Database of Systematic Reviews 2020, Issue 1. Art. No.: CD012547. DOI: 10.1002/14651858.CD012547. pub2. Available at https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012547.pub2/full?highlightAbstract=nutrit%7Cnutrition

www.NHDmag.com February 2020 - Issue 151

PUBLIC HEALTH

FOOD AND DRINK TRENDS IN 2020 Last year, the Mediterranean diet led the way as the top diet trend and the focus towards the end of 2019 was firmly on plant-based diets and flexitarianism. Will 2020 move us into a different direction?

Emma Berry Freelance ANutr NHS and University of Aberdeen Emma is a freelance nutrition writer and is interested in public health nutrition. She is also a PhD Student in Health Services Research and works in NHS Research and Development. Emjberr

REFERENCES Please visit the Subscriber zone at NHDmag.com

As our food and drink interests change, companies often try to guess what the next big thing will be. This means that they track what we buy, allowing them to predict upcoming trends. Towards the end of each year, organisations release their ‘top trends’ for the next year. This is becoming a trend in itself! OK, so the Mediterranean diet comes out on top for the third year in a row as the healthiest diet in the annual US News and World Report,14 with the DASH and flexitarian diets coming joint second. The Daily Mail reckons on ‘plant-based everything’ and alternative flours such as banana and coconut as big hits for 2020,15 whilst a report in The Independent on what’s healthy for 2020 provides us with some BNF advice: eat more salmon, oats and lentils.15 In late 2019, Waitrose UK1 and Whole Foods Market food chain in the USA2 released their food and drink trends reports for 2020. They both highlight some interesting insights. The Waitrose report is based on a survey of 2000 people from a range of backgrounds and not just exclusively Waitrose shoppers.1 They looked at various upcoming trends and also talked about some of the trends from the past year based on their sales.1 Foods topping their 2019 charts included: • tahini, noodles and grains, with grains such as amaranth and mixed grain pouches being particularly popular; • luxury frozen foods, posh crumpets and celery juice; • seaweed, such as aonori – Waitrose even stated that there has been an increase in 'seaganism', a diet including sustainable seafood;

www.NHDmag.com February 2020 - Issue 151

• vegan ready meals, overtaking vegetarian ready meals – the most popular being the mushroom carbonara and paella. THE UK: WHAT WE EXPECT TO SEE IN 2020

A continued interest in Middle Eastern food and cooking Many people enjoy foods such as falafel, hummus or even the occasional kebab. However, Waitrose advise that the sales of herbs and spices such as sumac, baharat and zaatar are rising, suggesting that we are cooking more Middle Eastern food at home too.1 A change from using salt to a range of different seasonings There has been a rise in the number of British people who enjoy spicy food. Adding chilli, chilli flakes or hot sauces to food has become more common in recent years. Waitrose suggests that more people may add seasonings such as nutmeg or basil to add new dimensions to their food.1 Also, if we are aiming to reduce our salt intake, swapping salt for new herbs and spices means we could get additional health benefits,4 for example, studies have looked into the antioxidant properties of cloves, cinnamon and oregano13 and there has been research into turmeric and its anti-inflammatory properties.4 Thinking of animal interests There is a continued reduction in the amount of meat and fish being eaten, with more people choosing a flexitarian

PUBLIC HEALTH or plant-based diet.5 People are spending more money on vegan products and major supermarkets are catching on and stocking up on vegan-friendly food. Waitrose is also saying it expects to see an increase in consumers choosing products that have better animal welfare standards too.1 New seafood trends A new trend, which started off in Australia, using seafood for charcuterie instead of meat,1 gives people the opportunity to be inventive and presents seafood in new and exciting ways. This trend may help increase the frequency of seafood in our diets. Currently, the UK guidelines recommend at least two portions of fish per week (280g), but the British Nutrition Foundation found that the average adult only consumes 54g of fish per week.6 Choosing less alcohol Waitrose also suggest an increased interest in non-alcoholic drinks with many people choosing non- or low-alcohol drinks instead of the alcoholic option, leading to new drink options being developed to suit this market.1 TRENDS IN AMERICA

In America, the Whole Foods Market chain has also released its top 10 trends for 2020.2 This list contains similarities to the Waitrose report. The expected trends include: • products that encourage ‘regenerative agriculture’ by using farming practices that work to improve the environment and reduce problems such as soil degradation; • new flours such as cauliflower or banana; • West African foods, healthy refrigerated snacks, fancy food for kids, different sugar and sweeteners; • vegan options without soy, vegan spreads and sustainable palm oil products; • flexitarian burgers, which involve mixing meat and plants together in one product; • new alternative products to alcoholic drinks. Both reports featured in this article highlight a strong interest in sustainability and plantbased foods, which is unsurprising given the general rise in vegan and flexitarian diets.5

A move to a more plant-based diet has been linked to increased fibre consumption and offers multiple health benefits.7 People are also more aware of animal rights and environmental issues, which are factors that influence them to choose plant-based options.5 Vegan diets have the biggest impact on the environment, by being more sustainable than our traditional meat-focused diets.8 Even by just reducing how often we consume animal products could have a positive effect on the environment, as well as on our own health.7,8 However, the use of palm oil and soy within food is an important consideration for the environment. Many individuals are concerned about deforestation and the effects on the animals that rely on this habitat due to the palm oil and soybean industries.9,10 There is an increasing selection of meat-free alternatives based on soy; therefore, being mindful of what we are eating even when reducing our meat consumption is important to help the environment. We are also considering the link between food and health via the inclusion of nonalcoholic alternatives.1,2 The recommended alcohol consumption in the UK is no more than 14 units a week on a regular basis for both men and women.11 Alcohol can have an impact on our mental health as well as our physical health, as it is linked to an increased risk of depression and anxiety.12 A wider variety of non-alcoholic or low-alcohol drinks may encourage consumers to choose these options, and so help reduce the impact that alcohol has on health. CONCLUSION

Overall, it is interesting to see the changes in our food and drink tastes demonstrated by these two reports. The similarities between UK and USA food trends are not surprising, however, it is worth noting that these reports highlight trends that are unlikely to provide a consistent picture across the UK or the US, as both supermarket chains will have targeted specific consumer demographics. Nevertheless, including more plant-based foods, non-alcoholic alternatives and a variety of herbs and spices in our diets, looks to be beneficial for our health and wellbeing in this new decade and beyond. www.NHDmag.com February 2020 - Issue 151

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COVER STORY

SATURATED FAT AND HEALTH: FRIEND OR FOE? The consumption of saturated fat (SFA) and its role in disease prevention has been hotly debated in the past few years, with some stakeholders questioning the relevance of this guideline for public health. So, where does the debate come from and what is the current available evidence actually saying? In August this year, the latest report on SFA and health from the Scientific Advisory Committee on Nutrition (SACN) maintained the reference value for SFA unchanged, recommending that SFA should not contribute to more than 10% of total energy intakes (see Table 1).1 According to the latest National Diet and Nutrition Survey (NDNS), published in January 2019,2 British adults aged 19-64 years consumed in average 11.9% of their total dietary energy (including alcohol) from SFA. The proportion is higher in children aged 4-10 years (13.0%), in teenagers aged 11-18 years (12.4%) and in older adults aged 65-74 years (14.3%). In all age groups, the foods contributing the most to dietary SFA are mainly meat and meat products, dairy products and cereals or cereal products (pizza, biscuits, buns, cakes, pastries, fruit pies and puddings). This leaves most Britons exceeding the current recommendation that SFA should not exceed 10% of total energy. WHERE DOES THE DEBATE COME FROM?

In 2014, a group of researchers published a paper challenging the relevance of the current guidelines on SFA.3 Their conclusion that evidence does not support current guidelines of reducing SFA for the prevention of cardiovascular diseases, was heavily reported in the media, with sensational headlines stating that, â&#x20AC;&#x2DC;Butter is Backâ&#x20AC;&#x2122;.4

Headlines like this, along with other studies or opinion papers showing no associations between SFA consumption and cardiovascular disease risk,5,6 popularised the idea that high SFA consumption does not increase the risk of cardiovascular diseases. This debate has caused confusion amongst the public and a lack of trust in public health guidelines, whilst reinforcing the existing beliefs in certain communities of people who follow high-SFA diets like keto or paleo.

Laury Sellem Freelance Nutrition Consultant and Doctoral Researcher After pursuing a BSc and MSc in Nutrition in France, Laury is now a PhD candidate in the University of Reading. Her research focuses on dietary fat and cardiovascular health. www.lauryfrench nutritionist.com thefrenchnutritionist laurysllm

NUTRITION RESEARCH IS NOT BLACK AND WHITE

Unfortunately, the heavy media coverage of the aforementioned studies failed to critically assess the methods used by researchers to form their conclusions. As often in science, nutrition studies always have limitations, preventing researchers from formulating clear cut conclusions. The 2014 paper from Chowdhury and colleagues, which re-initiated the debate on SFA and cardiovascular health, is a great example of the lack of nuance often seen in the media.3 In their study, the researchers compiled the results from several individual studies on SFA and cardiovascular diseases, in order to get a clearer image of the overall effect of SFA. This type of study, a meta-analysis, is often considered the most reliable evidence when it comes to nutrition research. However, meta-analyses need

REFERENCES Please visit the Subscriber zone at NHDmag.com

www.NHDmag.com February 2020 - Issue 151

COVER STORY Table 1: UK government dietary recommendations for energy and macronutrients and salt for men and women in the UK Energy (adults 19-64 years old)

2500 kcal/day for men; 2000 kcal/day for women

Proteins

0.75g of proteins per kilogram of bodyweight

Total fats Of which - Saturated fats

Reduce to about 35% of dietary energy

MUFA

No specific recommendations for MUFA

n-6 PUFA - Linoleic acid - Long chain n-3 PUFA - Alpha linolenic acid

6.5% of dietary energy - Provide at least 1% of total energy - There is no specific recommendation for long chain n-3 PUFA in the UK. Most health organisations recommend a daily intake between 250-500mg/day - Provide at least 0.2% of total energy

Trans fats

Provide no more than about 2% of dietary energy

Carbohydrates Of which - Free sugars - Dietary fibre

Approximately 50% of total dietary energy

Salt

6g/day

to be conducted in a rigorous way to ensure that all the individual studies included in the overall analysis are comparable. The comparability of all studies is one of the main limitations of the analysis conducted by Chowdhury and colleagues. Indeed, they looked at the reduction of SFA from the diets, without assessing the overall dietary patterns of participants, or whether SFA was being replaced by carbohydrates, proteins, or unsaturated fat. However, this major caveat was not discussed in the articles published in the media aimed at the general public. More importantly, Chowdhury and colleagues admitted in their paper that their analysis could not establish with certainty that reducing SFA would not lower the risk of cardiovascular diseases. Indeed, the studies they included in their analysis provide observational evidence. In this type of study, researchers follow a large number of people over time, observing their dietary habits and then looking at participants who will develop certain diseases. Thanks to their observations, they can can make conclusions on associations between exposures (here, the consumption of SFA) and health outcomes (here, cardiovascular diseases). However, the lack of association between the two is not sufficient to rule out SFA as a potential cause of disease. 12

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- Reduce to no more than about 10% of dietary energy

- Should not exceed 5% of total dietary energy - 30g/day

LOW-SATURATED FAT DIETS ARE NOT ALL EQUAL

As most people are likely to maintain a constant energy intake over time, reducing SFA from the diet often means compensating with an increase in other nutrients. In particular, reducing SFA can be associated with an increase of carbohydrates or other type of fats like polyunsaturated or monounsaturated fat. In their 2019 report,1 SACN performed 47 meta-analyses on SFA and a number of health outcomes, including body composition, cardiovascular diseases, blood pressure, Type 2 diabetes, cancer and dementia. SACN concluded that dietary SFA should be mostly replaced with unsaturated fat, with more evidence showing benefits of replacement with polyunsaturated compared to monounsaturated fat. In contrast, the few studies investigating the effects of replacing SFA with carbohydrates suggested that this eating pattern could be linked with increased risk of coronary heart disease7 and increased fasting insulin levels.8 Nonetheless, the research on carbohydrates as a replacement for SFA is still limited and the SACN report did not find clear evidence on overall cardiovascular diseases, cancer, Type 2 diabetes, body composition or blood pressure.

COVER STORY Finally, SACN reported no significant effect from replacing SFA with proteins, which reflects the contrasted evidence available on this topic so far. The effect of protein on heart health could depend on the source of protein, with some studies suggesting that replacing SFA with animal proteins could be associated with an increased risk of cardiovascular diseases,9 whilst plantbased protein may have the opposite effect.10 SFA AND HEALTH: SUMMARY FROM THE 2019 SACN REPORT

Amongst the numerous health outcomes investigated by SACN,1 the current evidence base was too limited or poorly designed to draw conclusions about the effect of reducing SFA on stroke, blood pressure, Type 2 diabetes, markers of glycaemic control (i.e. fasting glucose and insulin levels) and dementia. Cardiovascular diseases The authors reported that reducing dietary SFA is likely to decrease the levels of circulating cholesterol (both HDL-cholesterol and LDLcholesterol), but may not impact other blood lipids like triacylglycerides. This is particularly relevant for cardiovascular health, since elevated LDL-cholesterol is an important risk factor in the development of cardiovascular diseases.11 This finding was more consistent when SFA was replaced by either polyunsaturated fat (which constituted most of the available studies) and monounsaturated fat, rather than carbohydrates. Cancer The pooled analysis of observational studies on cancer revealed that a link between SFA and cancer is unlikely. However, SACN only investigated the risks of colorectal, pancreatic, lung, breast or prostate cancers. Moreover, the lack of well-controlled intervention studies, which are considered as the ‘gold standard’ to establish cause-effect relationships, prevented the authors from firmly concluding on SFA and cancer risk. RESEARCH ON SFA: WHAT’S NEXT?

In order to tackle the ongoing debate on SFA in national guidelines, for the prevention

of cardiovascular diseases, research on personalised nutrition is making substantial progress. In particular, researchers have suggested that the lack of clear associations between SFA consumption and the risk of cardiovascular disease in meta-analyses could be due to the fact that the metabolic response to a high-SFA diet could vary amongst individuals: some people would have elevated LDL-cholesterol if they consume high amounts of SFA, whereas others could maintain stable LDL-cholesterol levels.12 Ongoing research in the Universities of Reading, Surrey and Imperial College London, is trying to investigate the mechanisms underlying this phenomenon.13 Findings could then contribute to the evidence base for more personalised recommendations on SFA consumption. Moreover, emerging research suggests that the food sources of SFA could have different effects on health. In particular, the consumption of dairy foods is consistently associated with unchanged or decreased risk of cardiovascular diseases, despite being important sources of SFA in the British diet.14 Thus, studying SFA in the context of wholefoods and dietary patterns would provide a different perspective on their place within a healthy diet. TAKE HOME MESSAGES

• The current national guidelines recommend that SFA should contribute to a maximum of 10% total energy to prevent the risk of cardiovascular diseases. • In average, the British population still exceeds this recommendation. The biggest contributors to SFAs are dairy and meat products. • The relevance of this recommendation has been hotly debated, mostly due to oversimplification of the evidence in the media. • Nonetheless, current evidence consistently suggests that replacing SFA with unsaturated fat may reduce the risk of cardiovascular disease and may help lower LDL-cholesterol levels. • In contrast, replacing SFA with carbohydrates may not have such beneficial effects on health. www.NHDmag.com February 2020 - Issue 151

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NEW ADDITION: NUTRISON PROTEIN PLUS ENERGY This information is intended for Healthcare Professionals only. Accurate at time of publication, February 2020. Please visit www.nutriciaHCP.com for more information. The Nutrison Range are Foods for Special Medical Purposes and must be used under medical supervision.

CLINICAL

NUTRITION SUPPORT FOR ONCOLOGY Malnutrition is a common issue in the oncology setting and can be a tough challenge for dietitians working in this area. This article examines the factors contributing to decreased appetite, the nutrition assessment involved, as well as treatment guidelines. Weight loss in cancer is varied depending on tumour type. Pancreatic and gastric cancers lead to the highest frequency of weight loss, while the lowest frequency of weight loss is seen in non-Hodgkin’s lymphoma, breast cancer, acute nonlymphocytic leukaemia and sarcomas.1 Malnutrition in the oncology setting leads to impaired quality of life, a higher degree of treatment toxicity, reduced response to treatment, prolonged hospitalisation and an overall worse prognosis. CONTRIBUTING FACTORS

Decreased appetite and decreased dietary intake Appetite may be decreased for a variety of reasons including cachexia. However, a decreased appetite in an individual with cancer does not automatically mean they have cachexia and vice versa. Appetite could be reduced due to fatigue, increased effort required to prepare meals, low mood, stress, increased pressure at mealtimes from family members and a multitude of other reasons. Research is limited with regards to the spontaneous dietary intakes of individuals with cancer. However, studies indicate that intakes may be around 2426kcal/kg/day.2,3,4 Unfortunately, there is a variety of methodological issues in assessing dietary intakes that can lead to under and over reporting. Increased requirements Many researchers have identified increased resting energy expenditure

(REE) in individuals with cancer.4,5,6 Bosaeus et al (2001)3 found that around 48.5% of patients with cancer were hypermetabolic, with REE >110% of predictions. Increased resting energy expenditure showed a stronger association to weight loss than energy intake. This finding confirms previous research, which showed that REE increases progressively as increases in calories provided are increased to exceed the basal REE.7 This research reiterated the theory that increasing energy provisions in hypermetabolic patients with cancer is of limited benefit due to a physiological response to high feeding with increased metabolic expenditure. Side effects of treatment A decrease in sense of taste and changes in taste sensation leading to “a bad taste in the mouth” are common side effects of chemotherapy treatment.8 Further issues, such as pain, fatigue, nausea, diarrhoea, constipation, oral ulceration, difficulty chewing, thick saliva and swallowing difficulties, all contribute to decreased food intakes.9,10

Clare Thompson Locum Dietitian, Piers Meadows Recruitment Clare has a varied career moving around dietetic departments in the North of England and South of Scotland. theroamingdietitian TheRoamingRD

REFERENCES Please visit the Subscriber zone at NHDmag.com

Cachexia Cancer cachexia is characterised by negative protein and energy balance, coupled with systemic inflammation and an involuntary loss of lean body mass with or without wasting of adipose tissue.11 Weight loss in cachexia is different from weight loss in starvation. In starvation, fat is metabolised in www.NHDmag.com February 2020 - Issue 151

CLINICAL Table 1: Diagnostic grading of weight loss in cancer and the prognostic significance of these changes Grade

Weight Changes

BMI

Median Survival

Grade 0

Weight stable

≤25kg/m2

29 months

Grade 1

Weight loss ≥2.4% Weight loss 2.5 to 6%

20 to 25kg/m2 ≤28kg/m2

14.6 months

Grade 2

Weight loss 2.5 to 6% Weight loss 6 to 11%

20 to 28kg/m2 ≤28kg/m2

10.8 months

Grade 3

Weight loss <6% Weight loss 6 to 11% Weight loss 11 to 15% Weight loss >15%

≤20kg/m2 20 to 28kg/m2 22 to >28kg/m2 ≤28kg/m2

7.6 months

Grade 4

Weight loss 6 to 11% Weight loss 11 to 15% Weight loss >15%

≤20kg/m2 ≤22kg/m2 ≤28kg/m2

4.3 months

the liver to produce ketones and fat replaces glucose as an energy source; an individual who is starving loses mostly fat and a very small amount of muscle, but in cachexia, weight is significantly lost from muscle and some fat. The best management strategy for cancer cachexia is to treat the underlying cancer, as this will completely reverse the cachexia syndrome; however, this is not possible in a large proportion of cases. The second option is to increase nutritional intakes. Unfortunately, anorexia is often only part of the problem and, therefore, nutrition support is not able to completely reverse the wasting associated with cachexia, but is able to promote a more optimal nutritional balance and improve survival.12 NUTRITION ASSESSMENT

Early identification of issues that may contribute to poor nutritional intakes and early education regarding the effects of weight loss on survival in cancer are paramount to improving prognosis. Cancer patients referred late in their disease trajectory for cachexia may be at a point where intervention may be less beneficial.13 An international consensus group.14 incorporated weight loss and BMI into diagnostic criteria used to stratify the severity of cancer cachexia (see Table 1). This grading allows clinicians to identify and prioritise patients with the greatest need and provides them with a tool that helps to influence the aims of treatments. Assessment must include reviewing inflammatory markers, including C-reactive protein (CRP), albumin, white cell count (WCC) and 16

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neutrophil to lymphocyte ratio.15 Alongside a full clinical history including side effects, prognostic indicators must be assessed prior to planning an appropriate nutritional treatment plan. Wide ranging equation suggestions have historically been used to estimate requirements in cancer patients. Early research suggested that total energy intake should be 1.7-2 times the calculated basal metabolic rate for patients with cancer.16 Further research suggested patients should be fed to 115-130% of measured REE if nutritional maintenance is the goal, or up to 150% of REE when aiming to improve nutritional status.17 Furthermore, increased recommendations of 35-40kcal/kg of non-protein energy and 0.25-0.3g nitrogen/kg/day were recommended for malnourished cancer patients undergoing major surgery. Previous suggestions of 30% additions to the estimated BMR using Harris Benedict or Henry equations have been used, whilst current ESPEN guidance suggests 25-30kcal/kg/day and 1.2-1.5g protein/kg body weight. This variety in recommendations leads to varied practice amongst dietitians. Reeves (2004)18 identified a large variation in dietetic practice for estimating patients’ energy requirements. She identified that predictive equations did not estimate REE within clinically acceptable limits of the traditional gas exchange indirect calorimeter, and indicated that dietetic practice should focus on direct monitoring of energy intake and patient outcomes, such as weight, body composition and nutritional status, to determine whether energy requirements are being met, rather than focusing on the initial calculation.

CLINICAL Table 2: Evidence for drug therapies in cancer cachexia Drug

Description and side effects

Evidence of effect

Glucocorticoids

Prednisolone/dexamethasone are known to stimulate the appetite; however, side effects include insulin resistance, immune suppression, muscle myopathy and risk of adrenal insufficiency.

Dexamethasone has been shown to decrease the loss of appetite and decrease the amount of weight loss; however, this has not been found to have any impact on weight gain.21

Magestrol acetate (MEGACE, also seen as MA in some literature) and Medroxyprogesterone (MPE)

Orally active derivatives of progesterone. It is mostly an unknown pathway; however, it’s postulated that MEGACE may stimulate the synthesis, transport and release of neuropeptide Y. MPE decreases production of serotonin and cytokines (IL-1, IL-6 and TNF-α). Unfortunately, serious consequences such as thromboembolism, adrenal insufficiency and hypogonadism have been reported.

MEGACE improves appetite and is associated with slight weight gain. When compared to a placebo, MEGACE showed an improved quality of life.22 MPE has been shown to improve appetite and food intake, leading to stabilisation of body weight.23

Ghrelin

A naturally occurring hormone which is responsible for food intake regulation, gastrointestinal motility and acid secretion in the GI tract.

Improvements in lean body mass, total body mass and hand grip strength.24

Cannabinoids

The mechanism is yet to be clarified, but it is theorised that cannabinoids act via endorphin receptors and inhibit prostaglandin synthesis or inhibit IL-1 secretion.

Clinical trials have failed to show any benefit of cannabinoids when compared to MEGACE or a placebo.25

Melanocortin-4 (MC4) stimulation causes anorexia and weight loss, paired with increased metabolic rate.

In animal models, MC4 antagonists have been effective in preventing anorexia associated with cachexia and loss of lean mass.26 There are no human clinical trials available at this time; however, there is ongoing drug development in animal models.27

Both work to down regulate/block the production/effect of TNF-α and other pro-inflammatory cytokines.

Thalidomide has been shown to attenuate weight loss and loss of lean body mass.28 Mixed evidence of the effectiveness of etanercept and ongoing clinical trials to investigate this.29

5-hydroxytryptamine 3 blockers, with anti-nausea effects, has the side effect of increased appetite, which can be utilised.

Evidence suggests treatment of mirtazapine for eight weeks to cancer patients without depression resulted in weight gain and improved appetite.30 Olanzapine has been utilised alongside chemotherapy, resulting in a trend towards weight gain.31

Melanocortin antagonists

Thalidomide and Etanercept

Mirtazapine/ Olanzapine

TREATMENT GUIDELINES

As discussed previously, nutrition interventions in cancer patients have shown mixed results. Improved energy intake, improved functional status and improved quality of life have been identified following nutrition counselling and supplementation.19 Other studies identified no changes in weight or quality of life following

nutrition counselling.20 These differences may be related to the quality of nutrition counselling. However, this is difficult to assess in a research setting. A mixed approach of pharmacological and non-pharmacological interventions has been shown to significantly improve appetite and increased weight in a third of patients who www.NHDmag.com February 2020 - Issue 151

CLINICAL Table 3: Benefits and evidence for use of ONS Supplement

Glutamine

Carnitine

Mixed essential amino acids (EAA)

Omega-3 fatty acids

Benefit

Evidence

Considered to be conditionally essential in a catabolic state.

Prophylactic supplementation (10g every eight hours) in lung cancer patients undergoing radiation treatment had less weight loss when compared to a placebo.32

Low serum levels have been identified, likely due to decreased nutritional intake and diminished endogenous carnitine synthesis.

4g daily supplementation in advanced pancreatic cancer and cachexia increased weight, quality of life and showed a trend towards improved survival.33

EAA have been shown to induce greater anabolic responses than substantial mixed protein intakes, as large protein doses can suppress appetite.

L-glutamine (14g/day), β-hydroxyβ-methylbutyrate (3g/day) and L-arginine (3g/day) increased lean body mass in patients with advanced cancer.34 Higher anabolic potential than mixed non-essential amino acid supplementation in non-small cell lung cancer.35

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in fish oils have been suggested to downregulate the systemic inflammation associated with cancer cachexia.37

Fish oil supplementation (2g/day) during chemotherapy has been shown to delay tumour progression.36 Use of ONS containing EPA significantly improved energy and protein intake, body composition, loss of appetite, fatigue and neuropathy.38

returned for follow-up.13 Pharmacological options are discussed in Table 2. ESPEN guidelines recommend nutritional counselling focused on energy and nutrient balance, lifestyle, disease state, current intake and food preferences. Counselling must take into account the severity of symptoms/side effects and convey to the patient the reasons and goals of nutritional recommendations, whilst motivating the patient to adapt to their altered nutritional demand.15 Oral nutrition support, including food recommendations, food fortification and oral nutritional supplements (ONS), have shown benefit in terms of weight gain, increased BMI, and improved patient-generated subjective global assessment (PG-SGA) scores.9 Individual nutrient supplementations have also been explored in cancer with varied success rates (see Table 3). Unfortunately, in this setting, patients are looking for any option which may increase their chances of survival, which can include dietary restrictions lacking in any evidence base. Such diets include vegan, macrobiotic, ketogenic, 18

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sugar avoidance and many others, all of which may impact on nutritional intakes. The priority of nutritional counselling in cancer should focus on education of nutritional needs and the increased demands relating to their cancer diagnosis, and motivating patients to adapt their intakes based on this increased need.15 Prevention and early diagnosis of cachexia is treatable, whereas the final stages may be irreversible and focus should be shifted to palliative feeding approaches. SUMMARY

• Early identification is key to preventing the negative consequences of malnutrition in the oncology setting. • This early identification needs to be tied with education to newly diagnosed oncology patients to prevent the assimilation of nutrition misinformation. • In progressing cancer cachexia, the focus should be on attenuating losses in lean mass to preserve function and quality of life to improve survival. • Avoidance of overly restricted diets unless absolutely necessary.

NUTRITION RESEARCH

CANCER AND KETO Is a ketogenic diet (KD) the new anticancer treatment? This article aims to examine the research behind KDs and cancer, reporting on whether dietitians should be advising this approach to patients. The health-seeking behaviour of cancer patients is well documented1 and diet is one aspect, which often goes under the spotlight. The influence of the media has meant that more nutritional information is freely available to the public. Patients are becoming increasingly informed about their health,1 which may lead them to seek alternative diets and lifestyles when diagnosed with disease. KDs have seen a rise in popularity over the years, having been hailed as potential treatments for many conditions, such as weight loss, diabetes control and cancer. DEFINITION OF A KD

A KD is defined as a high-fat lowcarbohydrate diet. The exact macronutrient ratio of these components varies in the literature,2 but typically 3-4:1 fat to carbohydrate with the addition of protein.2 Other studies have also used other variations such as medium-chain triglycerides (MCT) KD, modified Atkins and low glycaemic index3 diet, as illustrated in Figure 1 overleaf. KDs have been used historically for the treatment of epilepsy in children caused by genetic defects, for example, Glut 1 and Pyruvate Dehydrogenase Deficiency,4,5 but have been hypothesised for treatment of other conditions such as cancer.6

Joanna Injore RD Specialist Dietitian: Oncology

KETOGENIC DIETS AS AN ANTICANCER THERAPY

The interest in KDs as an anticancer therapy initially stems from animal studies conducted by Warburg7 who found that cancer cells thrive on glucose even in the presence of oxygen to produce lactate. The theory behind the KD is to create an environment where there is low circulating blood glucose, thus depriving the cancer cells of their energy source. In this situation, the body is then forced to use lipids, which are metabolised into ketones for healthy cells to use as an energy substrate. Animal studies have shown KDs also decrease the initiation, progression and metastasis of cancer6 adding to the hypothesis for KDs as an anticancer therapy. CURRENT RESEARCH

Joanna is an experienced dietitian who has worked extensively in the NHS. She is Partnership Quality Lead at Macmillan Cancer Support and is the owner of JI Nutrition, which provides private 1:1 nutritional consultations and bespoke services for businesses. www.jinutrition.co.uk Ji_nutrition JInjore

REFERENCES Please visit the Subscriber zone at NHDmag.com

The preclinical and animal studies A recent article by Weber et al (2019)8 reviewed 87 studies on KD and cancer. They included 30 clinical studies and 57 preclinical rodent studies. The preclinical and animal studies showed promise, with 60% reporting an antitumor effect, i.e. adverse or reduced tumour growth and/or delayed initiation of tumours. Some studies also went further to propose that KDs caused cancer cells to be more receptive to conventional chemotherapy or radiotherapy treatment.9 Weber also hypothesised that there may be a www.NHDmag.com February 2020 - Issue 151

NUTRITION RESEARCH Figure 1: Macronutrient breakdown of the four major variations of KD presented as percentage of total individual estimated energy requirements Classic Ketogenic Diet 4:1

Medium Chain Triglyceride (MCT) Diet

Low Glycaemic Index Diet (LGIT)

Modified Atkins Diet

Adapted from Erickson et al, 20173

tumour or cancer-specific reaction to KDs as different responses were observed in studies in neuroblastoma and renal cell carcinoma.8 However, 17% of preclinical studies did not identify a change in tumour growth and 10% actually reported adverse or pro-proliferative effects. The remaining 10% of studies lacked control groups and the final 3% did not report on tumour growth, so conclusions could not be drawn from these studies. It is also worth noting that the majority of these preclinical studies focused on glioblastoma (an aggressive brain tumour). The clinical studies The evidence from the clinical studies included in the Weber paper was quite limited. Most were case reports or pilot/feasibility studies and reported on the safety of KDs or its acceptability to patients.8 Only one randomised controlled trial was available, which was conducted in ovarian and endometrial cancer patients. This did yield favourable results and showed the KD group patients had improved physical function, increased energy and less food cravings.10 Cohen et al later went on to report other 20

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benefits in women with ovarian or endometrial cancer,11 (although this paper was not included in Weber’s review). They observed a ‘reduction in total and visceral fat, maintenance, or lean body mass and a decrease in cancer-related growth factors’11 suggesting that the KD may have a role in this patient group. Another review by Sremanakova et al,2 also reported that the 11 clinical studies they identified were of low-quality evidence. These clinical studies had many issues that make us query the accuracy of their results. For example, these included limited information on recruitment, had limitations in their study design, did not adjust for confounding factors and lacked statistical analysis and power.2 In addition, all the studies used different versions of the KD (modified Atkins diet, Palaeolithic, 3-4:1-3:1 or 0.7-1.8:1 fat : carbohydrate ratio KDs, as illustrated in Figure 1). Therefore, these studies cannot be directly compared. In terms of nutritional assessment, only two studies reported on energy or macronutrient intake and a dietitian was not included in all the studies.

NUTRITION RESEARCH Table 1: Summary of the contraindications and side effects4 of the KD Weight loss Diarrhoea Fatigue Constipation Hyperuricaemia

Due to the current poor quality clinical evidence for KDs, they can't be recommended as an anticancer treatment.

Vomiting

A decrease in blood glucose level would be expected in those following a KD, but this was only measured in 10 studies in the Sremanakova review. In only four of these studies, there was a decrease in blood glucose, five had no significant change and one reported problems with maintaining glucose levels below 80mg dL.1,2 Changes in the blood lipid profile may be expected when following a higher fat diet and this was observed in four studies. Two studies observed raised cholesterol and low-density lipoprotein and the other studies reported reduction in low-density lipoprotein and highdensity lipoprotein.2 Unfortunately, it is difficult to draw clear conclusions on tumour reduction and overall survival rates on the available human studies2 due to the issues with the study designs and limited numbers of participants in each study. Overall, some diseases observed benefits to tumour reduction whereas others reported disease progression.2

Common adverse effects have been reported when following a KD (see Table 1).4 It is worth noting that these are also common treatmentrelated side effects, so it would have been interesting to know if these were accounted for in these studies,2,8 or whether they were intensified by following the diet. Compliance with the KD has been raised in a few studies. Sremanakova2 states that 51% of participants were unable to complete the diet in the studies they reviewed. Poor palatability of KD could possibly explain the reduced compliance, which has also been reported when these diets are followed for epilepsy.12 Significant time may be required in planning and preparing KD, which may be onerous to patients and their families. Thus, KDs may only be suitable for those who are highly motivated or have sufficient support. Regular, frequent nutrition counselling (possibly weekly reviews4) with a dietitian may be required, which may be difficult to achieve in a clinical setting.

POSSIBLE CONTRAINDICATIONS

RECOMMENDATIONS FOR CLINICAL PRACTICE

Since KDs do not align with conventional healthy eating messages, it is important to discuss the possible contraindications. All forms of the KD are considered â&#x20AC;&#x2DC;nutritionally inadequateâ&#x20AC;&#x2122; and require a multivitamin and trace element supplement; calcium and vitamin D supplements are also advised.12 Other contraindications may be particularly pertinent to cancer patients, such as weight loss, adverse side effects, as well as poor compliance with following the diet. Weight loss is often associated with KDs and was demonstrated in nine of the studies reviewed by Sremanakova.2 This would be a concern for cancer patients who may have already suffered unintentional weight loss, cachexia and treatmentrelated effects on their appetite or intake.

Due to the current poor quality clinical evidence for KDs, they can't be recommended as an anticancer treatment. Patients may request additional information regarding these diets and they should be informed of the limitations in the current clinical studies and potential adverse side effects before embarking on a KD. SUMMARY

Despite the strong theoretical argument and convincing evidence from preclinical and animal studies, the application of KDs in cancer remains inconclusive due to the limited clinical evidence. More robust randomised clinical trials are required before KDs become a standardised diet treatment option for cancer. www.NHDmag.com February 2020 - Issue 151

SPOTLIGHT ON . . .

Beth Bradshaw MSc BSc Registered Associate Nutritionist Beth has worked at Food Active, a healthy weight charity, for over two years and volunteered for a further 18 months. She has a passion for the wider determinants of health and working towards creating an environment that is more conducive to healthy lifestyles and behaviours. www.foodactive.org.uk Beth.bradshaw@ foodactive.org.uk food_active gulpNOW

REFERENCES Please visit the Subscriber zone at NHDmag.com

• A North-West response to the growing prevalence of obesity • Influencing policy at a local and national level to address the obesity crisis • Less victim blaming, more environmental framing England is in the midst of a major public health crisis. The country, its people and public services are grappling with the burden of diet-related diseases, including overweight and obesity. The situation is of significant concern given that the majority (64%) of adults in England are experiencing an unhealthy weight (classified as either overweight or obese)1 and a further one third (33.4%) of children are experiencing the same issue. There is a large body of evidence that suggests that obesity can harm people’s prospects in life, their selfesteem and their underlying mental health. On average, obesity deprives an individual of an extra nine years of life, preventing many individuals from reaching retirement age. Furthermore, obesity increases the risk of other noncommunicable diseases, including 13 different types of cancer, high blood pressure and Type 2 diabetes.2 The cost of treating such diseases is huge – the annual cost of obesity to the NHS alone is estimated at £6.1bn. The country now spends more on the treatment of obesity and diabetes than we do on the police, fire service and judicial system combined.3

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Introducing a new column highlighting organisations that support the dietetic and nutrition industry.

These problems are further exacerbated by health inequalities too. There is a strong relationship between deprivation and obesity, with obesity prevalence in Reception and Year 6 aged children doubling from the least deprived to the most deprived areas.4 In recent years, the approach to tackling obesity has been focused around behaviour-change interventions that help individuals to improve their dietary behaviours. Whilst such interventions have a role to play, they will be far less effective, when policies and one’s socio-economic environment do not support the individuals to action these changes in behaviour. It seems illogical to treat children for obesity, only to then send them back to the living conditions that made them obese in the first place.5 The issue is far more complex than what the current narrative suggests, and the sooner we change our approach, the better. That’s where Food Active comes in. A HEALTHY WEIGHT PROGRAMME

Food Active is a healthy weight programme of work delivered by the Health Equalities Group, made up of a small team of registered nutritionists and public health professionals originally based in the North West of England. The programme was borne out of a need to tackle greater levels of health inequalities seen in the region and the growing prevalence of overweight and obesity across the population. Our ethos focuses on less

SPOTLIGHT ON . . .

In February 2019, Leeds City Council signed the Local Government Declaration on Healthy Weight, joining the many local authorities already committed to the Declaration.

The checkout, end of aisles and store entrances are all well-established areas within store that are proven to drive sales . . . victim blaming, more environmental framing when it comes to tackling obesity. INFLUENCING POLICY

One prominent area we work on is influencing policy to address unhealthy weight at local and national level and advocating for populationbased approaches. In 2015, we launched the Local Government Declaration on Healthy Weight in order to support local authorities in implementing policies to promote healthy weight.6 The Declaration aims to help raise the issue of healthy weight within local government from transport to planning, to housing, as everyone has a role to play. If the causes are multifactorial, so must be the solutions, and efforts are required by a wide range of stakeholders, not just those within public health, in order to make change happen. The Declaration has now been adopted in 22 local authorities (correct as of January 2020) across England.

CAMPAIGNING AND ADVOCACY

In 2015, we launched our hard-hitting campaign Give Up Loving Pop!7 launched to raise awareness of the health harms of consuming too many sugary drinks. We provided a range of educational and community resources to amplify the message in the community, and run a 21-day challenge to pupils, staff and residents to go sugary-drink free. The campaign was also instrumental in the lobbying efforts that led to the announcement of a sales restriction on energy drinks to children in the Prevention Green Paper published in July 2019.8 It also influenced the introduction of the successful Soft Drinks Industry Levy in 2018 (aka the sugar tax), a national legislative policy targeted at reducing childhood obesity. The tax has resulted in a ~29% reduction in sugar (g) per 100ml,9 meaning as a nation, we are moving towards consuming less sugar, which is a crucial step towards addressing diet-related causes of weight gain. www.NHDmag.com February 2020 - Issue 151

SPOTLIGHT ON . . . Figure 1: Number of food and drink categories on promotion in the North West reported of the total sample11 Diet/zero sugar drinks

Yogurt Yoghurt

Water

Unspecified

Tea and coffee

Preserves

Sugar sweetened soft drinks

Pudding and desserts

Food and drink category

Pizza

Pasta, rice and pulses

Milk

Miccelaneous Miscellaneous

Meat products

Fruit juices and smoothies

Fresh, frozen or tinned fruit and vegetables

Fish products

Dairy free milk alternatives

Crisps

Chocolate and sweet confectionery

Cheese

Cakes and morning goods

Butter and margarine

Breakfast cereal and products

Bread

Biscuits

Alcoholic beverages

5 0

Number of cases reported

RESEARCH AND PARTNERSHIPS

We work in partnership with some fantastic organisations, such as the Obesity Health Alliance, to help build the evidence-base in support of policy restrictions that reduce children’s exposure to the marketing of less healthy food and drink. Children are bombarded with cues to consume less healthy food – ads on TV and on social media, messages on the side of buses, on bus tickets, on food packaging, use of their favourite characters, sponsored sporting events – the list is endless. Research has found that children can see up to nine adverts of unhealthy food in just a 30-minute period, including high fat, sugar and salt brands.10 In the same study, adverts for fruit and vegetables were found to make up just over 1% of food and drink adverts. How does this compare to 24

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the Eatwell Guide, which recommends that one third of the food we eat should be fruit and vegetables? The same pattern can be seen in the retail environment, whereby the promotion, whether it be by price or place, is skewed towards less healthy options. Our research with a group of just under 400 adults in the North West, demonstrated just that. Crisps, chocolate and sweets, yoghurt and sugar-sweetened beverages were the foods most commonly bought on promotion in supermarkets and were the spur of the moment impulse buys (see Figure 1).11 But it’s not just about price – where these products are placed is also a key driver in consumer purchasing habits. The checkout, end of aisles and store entrances are all wellestablished areas within store that are proven

SPOTLIGHT ON . . . Figure 2: Food and drink type by traditional non-food retailer13 Travel termini and ticket offices Bookshops Photo equipment and supplies Musical instruments Audio and visual entertainment stores Sport and outdoor retailer

Store type

Florists, garden centres and pet stores Telecommunications stores Games and toys Homeware stores DIY stores Pharmaceutical, medical and cosmetic stores Newsagents, stationary and gift stores Watches and jewellrey Clothing, textile and footwear stores Electrical household appliances Department Stores 0

100

120

Food and drink incidence Unhealthy food and drink options

to drive sales and evidence shows that the types of products usually found there are high in fat, sugar and/or salt.12 We’ve all fallen into the trap of picking up a pack of Percy Pigs whilst at the M&S checkout. Whether they have caught our eye in the chicane of the queue or we have been asked by an electronic voice at the self-serve if we would like to buy a packet, most often than not, we entered the store without even considering that we needed them. Such problems are not isolated to food retailers, however. Food Active and the UK Health Forum were commissioned by Public Health England to investigate the availability and marketing of less healthy food and drink in traditional non-food stores such as clothing stores, accessory stores, department stores and stationery stores. Findings indicated that less healthy food and drink is available and

Healthy food and drink options

Other

promoted via price and place across a range of traditional non-food retailers (see Figure 2).13 Since when did we need to pick up a packet of Haribo’s when buying a pair of earrings? SUMMARY

Everywhere that surrounds us, there are nudges and cues to consume the types of food that our government recommends we don’t. Confusing? Well, simply put, if we want people to eat better, we need to provide an environment that ensures that the healthy choice is the easy choice. Food Active, along with others, is building a movement to help those in power to put the health of the population first and make changes. A healthy population is the foundation of a healthy, happy and productive society, a vision that has been forgotten for far too long. www.NHDmag.com February 2020 - Issue 151

CONDITIONS & DISORDERS

OBESITY AND ENERGY METABOLISM: MicrObesity This article focuses on the review of currently known mechanisms by which microbiota can influence the pathophysiology of obesity and their potential applications to improve therapeutic strategies.

Bogna Nicinska RD Specialist Diabetes Dietitian, Oviva Dietitian by day, writer by night, Bogna has experience in research, community and acute care. Prior to Oviva, Bogna worked at Imperial College Healthcare NHS Trust as a Nutrition Support Dietitian.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Steeply rising numbers of obese individuals and the inadequacy of current therapeutic approaches to tackle the phenomenon, prompt the questions: “Is there something we don’t yet know about obesity?” and “What else can we do to help people fight this disease?”. The skyrocketing prevalence of obesity has become one of the most important public health issues affecting populations today. Between 1995 and 2016, the number of obese adults more than tripled, from 200 million to 650 million worldwide and the numbers continue to grow. Furthermore, obesity in children has become ever more common, reaching rates of more than 124 million worldwide in 2016. This prompts the assumption that there is a new generation of obese adults on the rise. Traditionally, obesity pathogenesis isolates genetic, behavioural and environmental factors, yet the poor effectiveness of many existing therapeutic approaches has stimulated the effort to consider the possibility of other factors involved in obesity genesis. If there are new causes found,

we could also identify new approaches, both preventative and therapeutic, to tackle the issue.1,2 HUMAN MICROBIOTA

In the last decade alone, more than 26,000 papers on gut microbiota have been published. Much of the research explores the microbiota’s association with body weight. The analysis of human microbiota began in the 1680s with a Dutch scientist, Antonie Van Leeuwenhoek, who had his own oral and faecal microbiota compared.3 Fastforward 300 years and research in the field is blossoming. We now know that a human microbiome comprises of 100 trillion microorganisms. Around 95% are based in the gut, mainly within the distal ileum and colon,4 which is home to more than 1000 bacterial species. The most numerous of these belongs to the phyla Firmicutes (60-80%). See Table 1. Some researchers call our endogenous microbiota a ‘microbial organ’ and estimate that 90% of diseases can be linked in some way back to the gut and health of the microbiome.15

Table 1: Examples of phyla in the human gut microbiota and related species5-14 Phyla

% in the gut

Species

Firmicutes

60-80%

Ruminococcus, Lactobacillus, Clostridium, Streptococcus, Staphylococcus, Eubacterium and Peptostreptocossus (see Figure 1)

Bacteroidetes

15-25%

Bacteroides, Prevotella, Xylanibacte

Actinobacteria

2.5-5%

Collinsella, Bifidobacterium

Proteobacteria

1-10%

Divided into several classes including: Alphaproteobacteria (eg, Chlamydia), Gammaproteobacteria (eg, Salmonella, Legionellales Vibrio, Escherichia coli), Epsilonproteobacteria Escherichia (eg, Helicobacter, Campylobacter)

Verrucomicrobia

0.1-2.2%

Akkermansia

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CONDITIONS & DISORDERS Numerous mechanisms have been revealed, which have the potential to contribute to obesity.9

Figure 1: Metabolic niches in the gut microbiome28

INTESTINAL PERMEABILITY

Changing factors like diet, age, sleep and stress can cause shifts in microbial communities, leading to intestinal inflammation and to dysbiosis. This imbalance can cause increased intestinal permeability, which results in increased translocation of immunogenic bacterial metabolites to the blood-stream. Studies indicate that dysbiotic microbiotaâ&#x20AC;&#x2122;s metabolites can alter gut hormone regulation and, through modulation of the vagus nerve, lead to overeating and weight gain.7,16 Bacterial metabolite lipopolysaccharide (LPS) can cause a similar effect, albeit with a different mechanism of action. A high-fat diet has been shown to boost the overgrowth of Gramnegative bacteria which produce an LPS. The compromised integrity of the intestinal wall increases absorption of endotoxin into the bloodstream, triggering pro-inflammatory cytokines production. Inflammation caused in this way alters hypothalamic gene expression, leading to central leptin resistance and obesity.5 Moreover, some studies conducted in rodents have demonstrated that LPS, combined with palmitate from a highfat diet, induced neuronal damage, impaired neurotransmission and neuronal death, leading to gut dysmotility.7,17-19 Despite proven, very positive effects of short-chain fatty acids (SCFAs) on the gut wall and satiety response, some research suggests that during dysbiosis SCFAs may contribute to obesity development. SCFAs are derived by some microbial species (especially Firmicutes) by anaerobic fermentation of dietary fibre. There have been several theories proposed as to how SCFAs may contribute to pathophysiology of obesity. One such theory states that during dysbiosis, production of SCFAs increases, providing an additional 10% energy of total daily

calorie intake.7,8 Other studies propose that SCFAs induce hepatic lipogenesis, increase triglyceride stores and regulate energy expenditure through expression of receptors in liver and adipose tissue, thus contributing to obesity.20 THERAPEUTIC POSSIBILITIES

It has been observed that injecting germfree mice with microbiota from obese mice can cause obesity in the host, which has inspired investigations into potential anti-obesity treatments. Routes that are currently being explored include prebiotics, probiotics, postbiotics and faecal microbiota transplantation (FMT).5,7 Prebiotics Research suggests that dietary prebiotics may delay or even prevent an obesity development through increasing growth of beneficial bacterial species in the gut, and subsequently their biproducts which have a positive metabolic effect. These nondigestible www.NHDmag.com February 2020 - Issue 151

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YOUR ESSENTIAL RESOURCE

CONDITIONS & DISORDERS Figure 2: Gut microbiota dysbiosis7

metabolites. More research is required to confirm their efficacy.7,23 FAECAL MICROBIOTA TRANSPLANT (FMT)

starches like inulin, fructooligosaccharides or galactooligosaccharides are contributing to intestine wall barrier enhancement, reversing dysbiosis and inhibiting lipogenic enzymes, consequently decreasing synthesis of triglycerides and lipoproteins.6,7 Probiotics There is ongoing research focusing on the properties of some bacterial species. Species like Lactobacillus, Bifidobacterium, Bacteroides uniformis, Clostridium coccoides and Akkermansia muciniphila have been shown to enhance intestinal gut barrier function through reducing inflammation of an adipose tissue and systemic inflammation in general, increasing serum leptin levels, decreasing postprandial lipid responses and LPS translocation.7,21,22 Postbiotics Bacterial metabolic byproducts (peptides, polysaccharides, enzymes and acids) could be useful in the manipulation of gut microbiota and modulation of related diseases. For instance, faeces of rats fed with a high-fat sucrose diet contained Clostridium genus metabolites. Making this association confirms the helpfulness of using metabolomics in evaluating the physiological effects of food and indicates the potential of postbiotics properties in anti-obesity treatment. So far, there have been indications for their potential beneficial anti-obesogenic, hypocholesterolemic, antihypertensive, and anti-inflammatory properties of bacterial

FMT is proven to be an effective treatment of recurrent Clostridium difficile infection. The traditional FMT procedure is radical, yet successful and currently its application in obesity treatment remains a strong interest of researchers. Scientists are even exploring the oral capsules with FMT solutions in obese patients. In 2019, a double-blind randomised pilot study was performed, with 22 randomly assigned obese patients receiving FMT capsules (derived from a single, lean donor: BMI, 17.5kg/m2), or placebo capsules over a period of 12 weeks. Participantsâ&#x20AC;&#x2122; stool samples at week 1, 4, 6, 8 and 12 were collected and analysed. Patients who received FMT capsules had sustained shifts in microbiomes associated with obesity toward those of the donor. The decrease in stool levels of taurocholic acid was observed and bile acid profiles began to resemble those of the donor. However, no significant changes in BMI were observed.24 So far, most of the FMT studies aiming for weight loss in participants are experimental and show no reduction in body mass index but reveal shifts in gut microbiota composition and insulin sensitivity. Although more clinical trials are needed, FMT treatment can be considered a promising obesity treatment.25 PREDICTIONS

Some researchers have suggested that gut microbiota composition at two years of age can be used as a predictor for obesity at age 12.26 If confirmed, this may lead to the development of a tool to identify children at risk of developing obesity. Moreover, other studies have indicated that certain gut microbes can help predict the likelihood of achieving weight loss with lifestyle interventions.27 Even though there is currently too little evidence to propose recommendations for the general population, these scientific insights into the microbiotaâ&#x20AC;&#x2122;s influences on the patho-physiology of obesity are paving the way for the design of innovative strategies for the management of obesity by targeting the gut microbiota. www.NHDmag.com February 2020 - Issue 151

COMMUNITY

DIET, FERTILITY AND IVF

Dr Mabel Blades RD Independent Freelance Dietitian and Nutritionist Mabel is a Registered Dietitian and member of the BDA Food Counts, Older People Specialist Group and the Freelance Dietitians Group. All aspects of nutrition enthuse her, and she is passionate about the provision of nutritional information to assist people in their understanding of dietary modification.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Nutrition and diet are vital considerations for women planning a pregnancy and for their health through each trimester and beyond. Nutrition also plays an important role in male fertility too. This article looks at the nutrients and supplements that have an impact on both female and male fertility. I became interested in diet and fertility during one of my first posts as a dietitian (and at that point in time, I was the only dietitian at the hospital), working with a gastroenterologist and his patients who were, frankly, malnourished due to various disease states. Often, patients identified a wish to have a family and, usually, I would see both would-be parents together. I still remember the first success vividly. The advice I gave was based on first assessing the diet and improving it with various foods, as in the late 1970s there was not the range of supplements available as there is today. Follow up was offered and weights checked alongside routine blood tests, with a discharge when things stabilised. During that time, one Friday, I was doing my general clinic and heard a kerfuffle outside; when I went out to look, I was met with a man holding out a beautiful baby to me and exclaiming, “My son is down to you!” Needless to say, all the waiting patients were looking at me wondering what had happened! The father’s delight was immense and this confirmed to me the importance of nutrition in fertility. In the late 1970s, experiments into in vitro fertilisation (IVF) began with the first baby born in 1978 and, now, such procedures are commonplace.1 Again, nutrition is important, but I am not clear if it is given adequate attention by centres. GOOD NUTRITION

Women planning a pregnancy are recommended to have a healthy balanced diet with regular meals, as a 30

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woman’s nutritional status at the time she becomes pregnant influences her health during the pregnancy. Obesity is linked with impaired ovulation and, thus, reproductive health and poor pregnancy outcomes both with natural conception and IVF. Weight loss prior to conception is reported to have beneficial effects on the reproductive outcomes in obese women.2 The UK National Institute for Health and Care Excellence (NICE) guidance advises that women with a BMI of 30kg/m2 should be encouraged to lose 5-10% of their body weight, detailing the health benefits that this provides, which includes increasing the chances of becoming pregnant.3 Undernutrition with a low weight and a BMI below 18.5kg/m2 is associated with irregular, or the cessation of, menstrual periods and malnutrition prevents ovulation and thus causes a reduction in fertility. If a woman is undernourished prior to conception, then her diet is likely to be deficient in a range of nutrients. The lack of nutritional stores in undernourished women may be unable to support embryo growth. While many of the studies focus on women, it is also apparent that diet also has an effect on male fertility and is receiving increasing attention, particularly as semen quality has declined over the past few decades. The change in diets, with an increase in total calories, as well as higher intakes of SFA and refined carbohydrates, may be associated with this trend.

COMMUNITY An international team of researchers who performed a systematic review of body weights and male fertility found that, as with women, obesity and being underweight had an effect on male fertility. A lower concentration of sperm was found in both overweight and obese men, as well as in underweight men when compared with men of a normal weight.4 MICRONUTRIENTS, SUPPLEMENTS AND FEMALE FERTILITY

Folic acid 400mcg per day of folic acid is commonly advocated for women who wish to become pregnant and while it is well recognised that it has a role in preventing neural tube defects, it also has a role in fertility. For any woman who is at increased risk of having a baby with neural tube defects (for example they have a partner with this condition), a higher level of folic acid is advised to be taken. Vitamin D NICE advises that a supplement of 10mcg of vitamin D should be taken by women throughout pregnancy and ideally prior to conception and this advice is echoed by the Department of Health.5 Vitamin D is integral to calcium balance and bone health but also various other actions including with the immune system, pancreas and intestine. There is also research to show links of an increased risk in multiple sclerosis in mothers who are deficient in vitamin D in the first trimester of pregnancy.6 Thus pre-pregnancy intake of vitamin D is likely to be important. Iodine More attention has focused on iodine recently with an increasing interest in plant-based milk alternatives which are lower in iodine and, thus, iodine intakes may be compromised. The UK iodine group advises that, based on World Health Organisation recommendations, 150 mcg of iodine should be taken each day by adult women with an increase to 250 mcg per day during pregnancy.7 MICRONUTRIENTS, SUPPLEMENTS AND MALE FERTILITY

Zinc Zinc intake is one of the foundations of male fertility as it is required for sperm and seminal fluid

formation. Zinc is a trace mineral, which cannot be stored in the body and thus a regular intake is required.8 Studies show that low zinc status or deficiency is associated with low testosterone levels, poor sperm quality and motility, plus an increased risk of male infertility. The Reference Nutrient Intake (RNI) for zinc increases from 7mg per day in 7-10 year-old boys to 9mg per day for boys aged 11-14 years, and then to 9.5mg per day from 15 years of age and, thus, increases with the advent of sexual maturity. Antioxidants Sperm is made up of mainly essential fatty acids and is prone to oxidative damage. One of the key items in maintaining the health of sperm, therefore, is antioxidants. Thus, an adequate intake of antioxidants is vital, with particular attention paid to selenium, which is protective against toxic heavy metals. Selenium also has a role in maintaining sperm motility. Sperm quality and motility is vital for conception to occur, with new sperm being produced every 74 days. Diet, stress and environmental pollutants such as from cigarette smoking and heavy metals, can all have an impact. Omega-3 polyunsaturated fatty acids (PUFAs) Improvements in PUFA intake increases the quality of sperm and studies have shown a better chance of achieving a live birth. The use of PUFAs in IVF is being examined.9 Alcohol The NHS information on Planning your pregnancy advises: ‘Do not drink alcohol if you’re pregnant or trying to get pregnant.’10 A study on alcohol consumption and IVF showed that there was a small decrease in the number of oocytes retrieved in women who consumed alcohol.11 CONCLUSION

Nutrition and fertility is a fascinating subject and one where there is a paucity of research. IVF is on the increase and the cost of this, not just the financial cost, but the time that needs to be invested and the emotional stress it can cause, makes IVF a process in which there are opportunities for Registered Dietitians to make an important contribution. www.NHDmag.com February 2020 - Issue 151

Balancing nutritional needs and caregivers’ aspirations

Isosource® Junior Mix is a nutritionally complete, safe and well tolerated1 tube feeding formula that contains ingredients derived from food.* Can be used as a sole source of nutrition for children from 1 to 10 years. Recommend Isosource® Junior Mix when your patient’s caregiver asks about blenderised diets. Visit www.nestlehealthscience.co.uk/ isosourcejuniormix for more information and to register for your copy of the recipe guide - coming soon. Food for special medical purposes. Isosource® Junior Mix is an enteral tube feed for the dietary management of patients with or at risk of malnutrition. Important notice: Use under medical supervision. Suitable for use as the sole source of nutrition. 1. Thornton-Wood, Saduera et al. To evaluate the acceptability (including gastrointestinal tolerance and compliance) of a paediatric enteral formula with ingredients derived from real food for children over 12 months of age. Abstract presented at ESPEN conference MON-LB699 Clinical Nutrition Vol. 38 Supplement 1 September 2019 S297-S322 S319. *13.8% of Isosource® Junior Mix is from rehydrated chicken meat and rehydrated vegetables, peach puree and orange juice from concentrate. For healthcare professionals only. ®Reg. Trademark of Société des Produits Nestlé S.A. 01/2020.

PAEDIATRIC

AN MDT APPROACH TO COMPLEX FEEDING DIFFICULTIES IN CHILDREN There is no uncertainty that multidisciplinary models of care across a number of dietetic, nutrition and health treatment modalities are gold standard and strived for amongst professionals. With a lack of robust guidelines for this area of paediatrics and due to the wide spectrum of disorders more frequently documented, a multidisciplinary approach is essential. Multidisciplinary working is widely referenced throughout NHS literature, including regular acknowledgment of its importance in provision of patient-centred care. The NHS defines the following: “A multidisciplinary approach involves drawing appropriately from multiple disciplines to explore problems outside of normal boundaries and reach solutions based on a new understanding of complex situations.”1 Within paediatric dietetics, multidisciplinary team (MDT) working is a wellestablished framework for management of certain conditions and referenced across guidelines for diagnoses such as cystic fibrosis, diabetes and food allergy. There are, however, certain pockets of paediatric dietetics that are currently yet to have such robust guidelines in place, largely due to the complex and heterogenous nature of clinical presentation, variability in management or treatment strategies, and/or lack of evidence-based treatment pathways. One such area relates to children presenting with feeding difficulties. Evidently, the term itself is broad in its reach, encompassing what may be considered ‘mild’ feeding difficulties such as fussy/picky eating, to more ‘severe’ feeding difficulties such as Avoidant Restrictive Food Intake Disorder (ARFID). The frequency of feeding difficulties is documented to

be as high as 30-50% of children;2,3,4 however, this is likely to represent a spectrum between normal feeding behaviours, misperceived feeding problems, milder feeding difficulties up to severe difficulties or ‘feeding disorders’.2 Studies report figures as high as 80% incidence for feeding difficulties in children with developmental delays due to chronic medical conditions,4 with interactions between medical, behavioural, developmental, social and/ or psychological factors more likely to be present in children with more complex or severe feeding difficulties.4 In practice, complex or severe feeding difficulties are likely to encompass, but not be limited to, children presenting with: • ARFID (fitting DSM V criteria); • feeding challenges, food refusal, oral aversion and/or highly restricted diets associated with developmental and/or motor delay, complex medical history, past feeding experiences, diagnoses such as food allergy, autism, sensory processing disorder or developmental disorders; • children requiring enteral nutrition to meet nutritional needs (‘tube dependency’) in the absence of dysphagia or with feeding skills +/- dietary modifications which can be adapted to meet nutritional requirements without requirements for enteral nutrition;

Lucy Upton, Specialist Paediatric Dietitian

Lucy Bates, Specialist Paediatric Occupational Therapist

Karen Sheffield, Specialist Paediatric Speech & Language Therapist The writers of this article are all part of the team at Integrated Therapy Solutions, providing multidisciplinary children’s therapy services for children in the Midlands. www.integrated therapysolutions. co.uk

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PAEDIATRIC At present, practice-based evidence would suggest that individual clinicians, including dietitians, are being increasingly confronted by the more severe end of the spectrum, where support goes beyond the scope of management by a single individual or speciality. Whilst parents and clinicians alike are starting to benefit from improved understanding and definitions of feeding difficulties such as ARFID, recent literature identifies that ‘severe or resistant’ cases require interdisciplinary feeding teams.5 In the interim, suggestions for firstline clinical settings include using a progressive approach to managing feeding difficulties such as identifying red flags, screening for oro-motor dysfunction and address feeding practices.5 PRACTICE-BASED EXPERIENCE

A reflection on working outside or without an MDT for children with complex feeding difficulties For children with complex feeding difficulties, it is not uncommon for a paediatric dietitian to already be involved, or to be one of the first professionals referred to for advice. Whilst there is certainly scope of practice for dietitians to support with factors including: growth requirements, nutritional optimisation, food allergy management, firstline behavioural advice and appropriate use of supplementation, further strategies for management can be variable based on practitioner experience, additional training and resources. Within practice, managing a child with more complex feeding difficulties can feel isolating, particularly in circumstances where the following occur: • Parents have already trialled and exhausted common behavioural management strategies for feeding difficulties. • You are unable to meet parents’ expectations of feeding support, or there is misunderstanding about the scope of dietetic input or remit. • Parents are evidently frustrated with inconsistency of advice, lack of availability of specialist services and/or time lags between input with differing professionals. • Resources are limited in terms of frequency or availability of further review, onward treatment pathways, evidence-based advice. • Further assessment has not yet been considered or carried out by other members of the MDT. 34

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• There is a lack of MDT working and either practitioners work in isolation at given times, or services are not commissioned for input of certain specialities such as occupational therapy or psychology for children with complex feeding conditions. Why is an MDT approach essential for this group of children? Complex feeding difficulties by their nature are multifaceted in presentation and, thus, management. Feeding is a highly complex task and unpicking each child’s journey is essential to management. In fact, understanding feeding difficulties in practice requires an understanding of multiple factors including, but not limited to the following: • the nutritional requirements of the child, taking into account any additional considerations such as food allergy or disease specific requirements; • alternative feeding options, eg, enteral nutrition; • infant and child development; • sensory processing; • motor development, including oro-motor development; • dysphagia; • the aetiology of medical conditions or diagnoses and their interaction with feeding; • pharmacology; • emotional and social development; • parenting styles; • early feeding experiences. Understandably, all of these cannot be unpicked from contact with a single professional! Research and literature widely acknowledge that an MDT approach is required for managing more complex and severe feeding difficulties, defining or outlining the essential need for: • a group or collective of specialists from multiple disciplines providing recommendations and treatment; • clinical feeding programmes, which include ‘multidisciplinary specialists involved using variations in assessment modalities and intervention strategies’.4,6 A recent systematic review and metaanalysis,6 which focused primarily on manage-

PAEDIATRIC ment of paediatric feeding disorders, indicated that, ‘intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties’, with those treated as such noted to have outcomes including increased oral intake, reduced parenting stress and improved mealtime behaviours.4,6 It does remain widely acknowledged, however, that there is still a need for further evidence and literature surrounding methodology, case definitions and standardisation of treatment. Considerations of parental stress and healthrelated quality of life outcomes for this group of children can also not be ignored. As detailed above, often parents have tirelessly trialled a number of interventions with minimal success and the burden of feeding cannot be escaped, remaining a non-negotiable part of everyday life. Research has noted that parents and individuals involved in the care of children with complex feeding difficulties feel personally responsible for their child’s disorder.7 There may also be medical issues coexisting, or contributing to the feeding challenges, with families adopting a ‘therapeutic’ parenting role already. A repetitive cycle between stress and anxiety around feeding, which in turn leads to food refusal or ‘failed’ mealtimes, can exacerbate food avoidance by the child alongside concurrent increases in parental frustration, anger and stress.8 Multiple studies highlight a negative correlation between high levels of parental stress and positive parent-child interactions for children with severe feeding disorders.8 Research identified that parental stress surrounding a child with feeding difficulties is better managed if their child is seen within an MDT feeding team and they are provided with a specific and specialised plan, receiving support from multiple disciplines on how to implement advice.8 Conversely, from a clinicians’ perspective, this group of children can be difficult to diagnose and treat – often challenging and multifaceted in presentation. The support of an MDT for each team member involved can be invaluable in managing the burden of patient care, coping with parental stress and expectations, dissecting the child’s complexity surrounding feeding and developing individual treatment

goals. Ultimately, working with a supportive and specialised team reinforces practitioner confidence, experience and their own stress management! AN MDT MODEL FOR MANAGING CHILDREN WITH COMPLEX FEEDING DIFFICULTIES

A service example: transdisciplinary feeding clinic and outcomes data Whilst a multidisciplinary model for managing complex or severe feeding difficulties is evidently crucial, there remains variability and flexibility in how this can be delivered, often resource allowing. Whilst there are a range of approaches and methodologies to delivering support and treatment for complex feeding difficulties, multicomponent interventions including use of factors such as behavioural support, learning theory, operant conditioning, systematic desensitisation and changes to environment and familial practices, have all been reported as effective.9 Within the UK, there are a number of specialist feeding clinics and teams already working within hospitals and trusts, such as Great Ormond Street Hospital, Evelina London and Addenbrookes Hospital. There are, however, evident disparities in service availability across the country and it is likely that there will be increasing pressure on the resources currently available, in light of increasing patient demand. Within the West Midlands (and in the absence of any local NHS specialised feeding teams), Lucy (Upton) has been fortunate to gain experience within a private paediatric feeding team for the past five years run through Integrated Therapy Solutions. Since 2012, the team has used the globally recognised transdisciplinary Sequential Oral Sensory (SOS) approach for assessing and treating children.10,11 The team consists of speech and language therapy, occupational therapy, nutrition and dietetics and clinical psychology. Close liaison with any NHS managing clinicians, including paediatrician are outlined as a requirement when families are enrolled. The MDT has so far supported children with a range of conditions including ARFID, autism, feeding difficulties associated with reflux and other gut problems, sensory-based feeding difficulties, food fear and refusal, tube weaning www.NHDmag.com February 2020 - Issue 151

PAEDIATRIC Figure 1: MDT feeding clinic outcomes

and motor-based feeding difficulties associated with neuro-developmental disability. The approach and delivery of support allows for key aspects of identified paediatric feeding teams4,5,9 including: • MDT assessment and input; • following an evidence-based approach for managing feeding difficulties, with pragmatic adaptation to a child’s individual needs; • consistency with delivery of advice/ approach and treatment protocol, agreed by all members of the team; • intensive support (including weekly contact if required), and intermediate contact via email or phone with families; • parental (and extended family) education to support confidence and ongoing delivery of therapy at home environment; • support with home, nursery, or school visits as required to ensure consistency of delivery and management; • modification or adjustments to the approach or treatment plan, alongside specific adjunctive therapy, with one or multiple therapists as required depending on the individual needs and/or presentation of the child. Following a detailed assessment, completed by all members of the MDT, treatment blocks last 12 months and incorporate: 36

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• education to help parents understand and treat feeding problems; • systematic desensitisation of underlying sensory issues; • achievement of normal developmental feeding milestones; • food hierarchies to explore new foods through therapeutic play; • set routines in sessions including perceptual preparation; • positive social reinforcement; • a child is progressed through a detailed 32-step programme of eating hierarchy with each new food; • daily repetition to transfer the programme outside of the clinic environment. OUTCOME DATA

As part of running a feeding clinic, practicebased evidence and family feedback is gathered as part of standard care. We complete a yearly retrospective cohort analysis of our outcomes to evaluate the effectiveness of the service. In order to do this, we use Goal Attainment Scaling (GAS),12,13 with bespoke goals for each child set at the outset of therapy, which are later subject to review. GAS allows for cohort comparability irrespective of individualised functional goals and differing diagnosis.12,13 Goals are weighted to take account of the relative importance of the goal to the individual and the anticipated

PAEDIATRIC difficulty of achieving it. A client goal set is converted into a summary score reflecting preand post-treatment goal attainment (T-score) – with the results summarised in Figure 1. Whist, evidently, this data reflects a small sample set, the majority of our children achieve a statistically significant post treatment T-score of 50, meaning the goals are achieved as expected. When our outcome data was broken down to provide further details and insight, we were able to extrapolate the following information: • Treatment goals are achieved within 12 months. • Our families attended an average of nine appointments and follow advice daily. • Children increase the variety of foods they eat after the programme. • All of the children and young people were discharged and were eating at least 30 foods including 10 starches, 10 fruits or vegetables and 10 proteins. • Our data reflects published research that children consume an additional 200 calories per day, on average, after the programme. • Our families report less mealtime battles, increased confidence with managing their child’s needs and helping their child make progress, plus a self-identified reduction in parental stress and anxiety. This initial data collection is highly encouraging, supporting both the efficacy of the service and also the recommendation for use of a transdisciplinary approach for managing children with complex or challenging feeding difficulties. We noted that two children failed to achieve a T-score of 50, so further investigated the reasons behind this. The first child had progressed well with exploring and interacting with new foods. However, he was experiencing specific anxiety and intrusive thoughts regarding eating these foods: “My tummy wants to eat them, but my head says they will hurt me.” Parents had not been able to access clinical psychology support due to financial constraints, which affected further progression. He would have benefited from additional clinical psychology support around these specific anxieties. The second child had a diagnosis of Down syndrome. He moved up the lower steps of feeding hierarchy at an

equivalent pace to the other children, but had difficulty progressing further. Post treatment, he went onto receive a secondary diagnosis of autism and in view of this he would have benefited from undertaking the adapted SOS feeding approach for autism, which takes a more gradual approach over a longer time. At present, families identify charitable or private funding sources to access transdisciplinary feeding therapy. This means that, despite an exceptionally high referral rate, not all families are able to access a full block of feeding therapy. Some families follow a modified educational approach as their financial circumstances allow and, as such, this data was excluded on the rationale that they followed a different treatment approach. THE FUTURE

Given the success of the service so far, and recognising the team's desire to be able to provide treatment for families unable to access private or charitable funding, we have just launched ‘The Feeding Trust’; a not-for-profit enterprise, offering treatment for children and young people who have complex feeding difficulties. By setting up The Feeding Trust we hope to support more families and increase the quantity of our practice-based evidence. By data capturing on a larger scale, we can evaluate the effectiveness of direct therapy against some of our other models of feeding therapy, such as; intensive therapy blocks, parent and child groups, school-based groups and parent education groups. We hope that this model of care, alongside similar MDT models across the country will continue to provide the specialist input this group of children benefit from, based not only on suggestions from literature around best practice, but from practice-based evidence too. If you would like any further information about The Feeding Trust, please do not hesitate to contact us: www.feedingtrust.org email: admin@feedingtrust.org thefeedingtrust facebook.com/The-Feeding-Trust www.NHDmag.com February 2020 - Issue 151

PAEDIATRIC

FUSSY EATING IN TODDLERS Fussy eating is common amongst toddlers and feeding a child can be a highly emotive experience, which can cause great parental anxiety. Parents need to be better informed about strategies to help prevent negative consequences of fussy eating for both families and future health.

Sarah Lindsay Brown RD, PGDip Specialist Paediatric Dietitian Sarah is a dietitian and founder of Teeny Weaning, with over 13 years of varied experience from industry, a non-profit organisation and private practice. She specialises in early years nutrition with a focus on weaning and fussy eating, facilitating workshops and consultations for parents, carers and families. www.teenyweaning. co.uk teenyweaning

REFERENCES Please visit the Subscriber zone at NHDmag.com

Eating preferences and patterns during the toddler years are strongly associated with those later in life and so toddler eating habits may have important implications on not only a child’s current health, but also on their future health. There are many strategies to help overcome fussy eating, but there are behaviours that can make it worse. Currently there is no universal definition for fussy eating, or an agreement on the best tool to identify it, making it difficult to compare studies.1 The most accepted definition is that ‘picky/fussy eaters are usually defined as children who consume an inadequate variety of foods through rejection of foods that are familiar (and unfamiliar) to them’.2 Neophobia; actual fear of unfamiliar foods, is distinct from fussy eating. Most fussy eating resolves over time with the right strategies, although in a small number of cases Avoidant Restrictive Food Intake Disorder (ARFID) can develop. ARFID is defined as an eating or feeding disturbance resulting in persistent failure to meet appropriate nutritional or energy needs (and not caused by another disorder such as anorexia nervosa).3 This includes significant weight loss, faltering growth, major nutritional deficiency, or dependence on enteral feeding and nutritional supplements. These cases need to be identified early to enable support.1,4 HOW COMMON IS FUSSY EATING?

It is difficult to identify prevalence. Most studies estimate the prevalence to be between 10%-30% of preschool/ 38

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primary age children.5 The UK Avon Longitudinal Study of Parents and Children (ALSPAC), found prevalence was 10% at age 24 months, 15% at 38 months and 14% and 12% at 54 and 65 months, respectively. In other words, fussy eating appears to peak at about three years.1 Notably, only 26% of children aged two to five years were never reported to be fussy.3 WHAT CAUSES FUSSY EATING?

It is believed that fussy eating is caused by a complex mix of child characteristics and the child-parent interaction.1 The evolutionary theory suggests that the rejection of vegetables in particular is explained by our innate liking for sweet, salty and umami flavours over bitter and sour ones.6 This is considered a survival mechanism given that bitter flavours are often poisonous in the wild. Additionally, as toddlers become more mobile, neophobia is believed to be a protective mechanism through fear of eating anything ‘unsafe’. Early feeding difficulties such as choking, vomiting or reflux, can lead to fussy eating. Children with autism regularly present with selective eating due to heightened sensory sensitivity. Children with food allergies or dietary restrictions, such as those with coeliac disease, can develop selective eating through fear of contamination.3 Genetics plays a part too. The Gemini birth cohort found that both food fussiness and neophobia showed considerable heritability.7 Genetic variation in sensitivity to taste may also play a role.8 On the other hand, there is strong evidence that early food preferences are

PAEDIATRIC

Consistency with feeding strategies is needed and change can be slow. Expectations need to be realistic to maintain motivation.

influenced by environment.9 Parenting styles have a great impact and this is discussed further below.

a baby’s facial expression when eating new foods as disgust when it is in fact a normal immaturity of oromotor skills.6

ARE THERE ANY REPORTED CONSEQUENCES OF FUSSY EATING?

Parental role-modelling: Eating the same foods has been shown to influence children’s consumption1,17-20 and be protective against later fussy eating.16,21

Overall, fussy eating hasn’t been shown to compromise macronutrient intake.1 Reported consequences include poor dietary variety with low intakes of iron and zinc being of particular concern,10 explained by low intakes of meat, fruit and vegetables. Additionally, low intakes of dietary fibre and associated constipation have been reported.1,11 In fact, a vicious cycle of fussy eating and constipation exists, whereby children with constipation develop fussy eating and visa versa.12,13 There is little evidence for any consistent effect of fussy eating on growth.14 There is likely to be a small subgroup of children in which fussy eating doesn’t resolve, who are at risk of underweight in the teenage years.1,15 WHAT STRATEGIES HELP OVERCOME FUSSY EATING?

Practices during weaning: Three approaches to weaning may help establish vegetable liking: vegetables first, frequently and in variety.6 Additionally, the early introduction of lumpy foods before 10 months is associated with a more varied diet and a greater variety of fruit and vegetable intake.6 Interestingly, providing ready-prepared food has been linked to fussy eating.6,16 What’s more, parents can misinterpret

Repeated exposure to unfamiliar foods: On average, parents will stop offering after three to five rejections,22 however, this doesn’t help with learning to like new foods. 10-15 positive experiences may be necessary for familiarity and trust, before tasting is even achieved.3,23,24 Increasing exposure increases familiarity, which in turn increases liking and intake. Exposure should be done in a positive, gradual and rewarded way. A child with extreme anxiety might need to go through a number of steps before tasting a disliked food. This may start with looking at the food in a shop,3 whereas a child with less anxiety may be able to start by licking a food. Additionally, looking at vegetable picture books has been shown to increase vegetable consumption.25 What’s more, growing food and cooking together has great benefits. Use non-food rewards and praise: Praise good eating behaviour. Rewarding with stickers has been shown to increase consumption of disliked vegetables.3 Non-food rewards can be given for tasting foods up to 15 times.3 www.NHDmag.com February 2020 - Issue 151

PAEDIATRIC Create a positive social mealtime environment, with positive encouragement: Have family meals whenever possible with everyone eating the same food and using positive language such as “Maybe you will like it tomorrow”.3 Positive comments about a child’s food has been associated with a lower risk of inadequate nutrition.26 Limit snacks and energy-dense drinks such as milk and soft drinks between meals. Avoid grazing and have a clear routine for meals and snacks.3 Don’t fear sweets as long as the majority of a child's diet consists of nutritious foods. However, there is limited room for high sugar/ fat/salt foods. Have a realistic expectation on children’s portion sizes: The British Nutrition Foundation have a useful resource, ‘5532 a-day’ on portion sizes for one- to four-year-olds.37 Serve vegetables first: This has been shown to increase the amount of vegetables consumed.3 ‘Parent provides, child decides’: The parent decides what, when and where the child eats and the child decides how much and whether they eat. This concept is referred to as the ‘Division of Responsibility’, as described by Ellen Satter (www.ellynsatterinstitute.org/). Children should be positively encouraged to taste, but allowed to choose if they eat and their appetite should be respected to enable them to learn about feelings of hunger and fullness. This approach is similar to a feeding style known as authoritative (warm). Parents with this style have reasonable nutritional demands and sensitivity towards the child. There are three other feeding styles: 1 Authoritarian (controlling, with little sensitivity towards the child) 2 Indulgent (permissive and with little structure) 3 Uninvolved (neglectful and parents don’t care what their child eats, or they care but cannot provide structure) In general, children of authoritative parents have the best outcomes in terms of healthy eating, self-regulation and lower food fussiness.27,28 40

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Limit mealtimes to 30 minutes.3 Focus on long-term goals: Parents need reassurance that a small appetite is ok and does not equal a ‘bad eater’. Short periods of low intake won’t harm a child of healthy weight, but the benefits of having positive, healthy eating environments are huge. Consistency with feeding strategies is needed and change can be slow. Expectations need to be realistic to maintain motivation.3 Online resources: Parents can be directed to online resources and local parenting courses if available. See Levene and Williams (2018) for resources for parents and professionals.3 WHAT STRATEGIES SHOULD BE AVOIDED?

Pressure to eat has been associated with fussy eating and decreased enjoyment of eating29 and may be partially mediated by concern about child underweight.30 Pressure to eat may actually decrease liking of target food.31 There is a bidirectional association between a child’s fussy eating and parental pressure.32 Furthermore, pressurising disrupts a child’s internal regulation for recognising fullness and hunger.33 Bribery or food rewards (eg, dessert): Food rewards seem to decrease acceptance of target food and increase consumption of reward food due to its increased desirability.34 Hiding foods: Although associated with increased short-term intake, hiding foods does not increase acceptance of the target food29 and can lead to loss of trust if a child finds out. Negative language: Warning children of the bad effects of eating certain foods and labelling foods as healthy may actually decrease vegetable intake.35 Use of overt restriction: Overt restriction may have the opposite effect to that intended and may actually increase consumption of unhealthy food, through increasing desirability.36 Distraction: Turn off the TV and have no toys at the table.21,27

PAEDIATRIC

Serve vegetables first . . . This has been shown to increase the amount of vegetables consumed.

Alternative meals: Don’t offer alternative meals if the original meal is refused.3 WHAT TO COVER IN A CONSULTATION3

• weight and height; • parental concerns and expectations – impact on a family’s life; • child's food diary – at least one food from each food group daily; • tried strategies and parents' approach to mealtimes; • any physical and psychological factors; • medical history – any conditions that may affect eating, eg, prematurity, constipation, reflux, choking, allergy; • any causes of discomfort during eating, eg, teething; • briefly explore parents' attitude towards food (any previous/current eating disorders?); • consider iron deficiency tests if diet is low in iron; • discuss follow up (can include health visitor and GP); • discuss vitamin supplements. WHEN TO SEEK FURTHER HELP?

It can be difficult to judge when intervention is needed. It has been suggested to base the decision on whether a child’s feeding behaviour could have negative consequences on health, development, education, psychological wellbeing, or socialisation. Some areas have feeding groups at local children’s centres. Some hospitals have

multidisciplinary services and these could include a paediatric dietitian, speech and language therapist (for those who gag or have problems with texture), occupational therapist, psychologist, nurse, consultant doctor and a neurologist, or neurodisability specialist, depending on a child’s needs. Suggested criteria for referral3 Those with: • ARFID leading to failure to meet nutritional or energy needs; • medically limited diets such as food allergy; • coexisting chronic disease such as diabetes or cystic fibrosis (support may be available through the specialist MDT); • learning difficulties or autistic spectrum disorders; • significant high levels of anxiety despite initial advice and follow up. CONCLUSION

There is a need for accessible parental advice and help with fussy toddlers so that they don’t develop into problem eaters. Focusing on long-term goals and being consistent with strategies, such as positive parental feeding, eating together and having a healthy home food environment, is likely to have real benefits. For most, fussy eating resolves, although follow up is essential, as there may be a subgroup in which the behaviour becomes persistent. The identification of these early on is critical. www.NHDmag.com February 2020 - Issue 151

SOCIAL CARE

Evelyn Newman Nutrition and dietetics advisor: care homes Award-winning dietitian, Evelyn Newman, is well known throughout the profession for her writing, volunteering with the BDA and innovative work. She currently holds a unique role in The Scottish Highlands. evelynnewman17

REFERENCES Please visit the Subscriber zone at NHDmag.com

TECHNOLOGY: TRANSFORMING WORKING LIVES Does technology play a role in social care and how can we maximise engagement using new and existing technologies? We are all more than happy to use technology in our personal lives; whether it’s a smartphone, tablet, fitness tracker, smartcards or even interactive games. We often connect with family, friends and wider networks using emails, various apps, through Facetime or Skype. But when it comes to using new or even existing technology at work, it can be a different story, can’t it? The logistics can be difficult. Why should patients be expected to make complicated childcare arrangements, arrange time off work, navigate public transport and find that they only need to see the specialist clinician – or maybe a locum or even a student – for only 15 minutes? The geography and transport infrastructure of The Highlands, coupled with the challenging weather at times, can mean that people are spending the best part of a day travelling to Inverness for one clinical appointment. Translate this scenario to a frail, elderly person and/or a carer making the same journey from their own home/or a care home; add in a diagnosis of dementia and the result can be very traumatic and cause unsettled, agitated behaviour for the days before and afterwards. This can be multiplied several times over, if an individual has a number of co-morbidities, as is often the case of course. The Scottish government has a national digital strategy,1 which proactively promotes a more personcentred approach to care delivery and

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flexible staff working arrangements. NHS Highland too, is changing things for the better and many of our patients are now offered consultations via a digital ‘Near me’ service, which allows them to have their specialist consultation from a local community hospital, health centre, or GP practice. We also have care homes offering video conference consultations, to save the stress of long journeys, which often can be in less than comfortable patient transport. As clinicians, we can often put too great an emphasis on what works best for us and would rather see someone in person, perhaps because it helps us feel more needed and in control. But even a phone call, a text, or an email can be all that our patients want or even need. In my own work, supporting 70 care homes and a variety of care-athome and day-care services, I could be permanently driving around delivering training or attending meetings. I’d enjoy the fantastic scenery, but I’d get very little done in the great scheme of things! Fortunately, I have the opportunity of engaging with lots more people in meetings and training sessions by using a variety of digital solutions, allowing me to limit my carbon emissions, reducing the cost to my employer and helping my health!

SOCIAL CARE DIGITAL SUPPORT IN HIGHLAND

Here are some of the useful resources and technologies that have helped and are helping me in my role: • A carefully crafted distribution list of two, means that I can reach social care staff with consistent evidenced-based information and updates, at the touch of one button. • Use of the BAPEN LearnPro module allows people to access some personal CPD from wherever they choose.2 • Hosting Highland resources, such as my quarterly Nutrition News, on the Scotland Care Inspectorate hub for older adults,3 allows social care staff to access information and links retrospectively if needed. You’ll also find a few YouTube clips from me there too. • Over the past year, I’ve been invited to speak with care-at-home staff, using a remote teaching model called ECHO. We can have up to 30 carers participating from some very remote locations, enjoying a coffee in their own surroundings, joining in the conversation, asking questions and learning in the comfort of their own lounge, or for small groups in more built-up areas. • I have participated in web-based Zoom meetings with colleagues in HEIs and care homes, planning student placements together and have put myself to the test by delivering two national webinars promoting nutritional care that is being delivered by so many Highland social care staff (nerve-wracking but worth it!). • Many of you will know that I am also a great advocate of twitter as a professional opportunity to learn and widely share aspects of working and supporting good nutritional care. I joined in 2015, as a requirement of completing the NES (NHS Education Scotland), having had little experience of using social media before. I now find it an invaluable tool, making best use of my time, effectively networking, influencing and learning. I have joined in several BDA-led Twitter evening chats from the comfort of my home and have used the platform to proactively promote dietary aspects of social care linked to national events such as Dietitians Week and Malnutrition Awareness Week. • I have written and delivered several articles on nutrition and social care topics for both Alzheimer Scotland the AHPScot blogs and was consequently asked to become the digital social media champion for my board NMAHP colleagues. • In November 2019 I was interviewed and appointed to the Scottish government dNMAHP leadership group, which I hope will also allow me to further encourage colleagues and service users alike to make digital the new, smarter way of working and supporting good health and social care over the coming year.4 Digital working has also allowed greater opportunities to navigate, interpret, compare and share a vast array of complex data, to effectively manage and reduce the use of ONS prescribing. Reviewing quarterly figures has allowed me and my colleagues to drill down to GP practice, locality and individual patient level. This has enabled local clinicians to examine and review prescribing practice; ensure that standard work

is being delivered; stop unnecessary use and the consequential waste. I sincerely hope that, by sharing my varied experience of effectively embracing a range of technology solutions at work, others will consider how they might free up some much-needed time to do other things (like write this article!). Even with my many years or work behind me, I still have the capacity of trying the latest digital platforms and media. Why don’t you try it too! www.NHDmag.com February 2020 - Issue 151

CONDITIONS & DISORDERS

POLYCYSTIC OVARY SYNDROME (PCOS) AND SYMPTOM MANAGEMENT

This article looks at lifestyle interventions for adults with PCOS. Alex Ballard Band 6 Community Dietitian Alex specialises in diabetes at the Essex Partnership University NHS Foundation Trust (EPUT). She is active on social media and has a keen interest in health writing, cooking, exercise and the environment. alextalksdiet

REFERENCES Please visit the Subscriber zone at NHDmag.com

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting approximately one in every 10 women of a reproductive age.1,2 It is caused by an imbalance of female sex hormones,3 which alters how the ovaries work.4 An individual with two or more of the following features4 may be diagnosed with PCOS: • Irregular periods, which means the ovaries do not regularly release eggs (ovulation). • Excess androgen: high levels of ‘male’ hormones (such as testosterone) in the body, which may cause physical signs such as excess facial or body hair. • Polycystic ovaries: the ovaries become enlarged and contain many fluid-filled sacs (follicles) that surround the eggs. PCOS is a syndrome and, therefore, is a collection of symptoms. See Table 1 for commonly associated symptoms. Individuals with PCOS are also at an increased risk of particular health conditions, such as impaired glucose tolerance, Type 2 diabetes, gestational diabetes, cardiovascular disease, sleep apnoea and psychological difficulties.1,5 Additionally, insulin resistance is estimated to affect approximately

50-80% of individuals with PCOS.3 Excess insulin can cause oestrogen to be converted into testosterone and exacerbate symptoms. Insulin resistance can occur irrespective of obesity and, therefore, needs to be screened for in all individuals.6 Fortunately, lifestyle interventions can improve hormone imbalance, symptoms, overall health and quality of life (QOL).7,8 Advice around diet, exercise and behaviour change should be first line for individuals with PCOS.5 WEIGHT MANAGEMENT

Being overweight or obese can heighten symptoms for individuals with PCOS, by worsening hormonal imbalance and increasing insulin resistance.3 Therefore, where appropriate, promoting weight loss in individuals with a body mass index of >25kg/m² is important. If overweight, weight loss of 0.5-2 pounds per week can improve outcomes.2 Guidance currently recommends gradual healthy weight loss by achieving an energy deficit of 500-700kcal per day.8 This should be from a nutritionally balanced diet,6 which is rich in fruit and vegetables and limited in processed foods.2 There is inconclusive evidence at present to suggest one particular type of diet to be the most beneficial.

Table 1: Common symptoms of PCOS2,4

Irregular or absent periods

Oily skin or acne

Hirsutism (excessive hair growth, particularly on the face, chest, stomach, back or buttocks)

Difficulty in maintaining a healthy body weight

Thinning of scalp hair or male-pattern baldness

Fertility problems

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CONDITIONS & DISORDERS

Lifestyle advice is essential for all women with PCOS to help manage symptoms, improve insulin sensitivity and reduce the risk of associated health conditions.

If standard weight loss strategies are unsuccessful, bariatric surgery may be an option for individuals with PCOS who meet the referral criteria.1 Regardless of the dietary approach that an individual chooses to follow, it is important to offer continued support and monitoring,6 as this can improve weight loss results.8 DIETS

Low-glycaemic index diet Glycaemic index (GI) is a ranking system that shows the rate at which a particular carbohydrate-containing food or drink will affect blood glucose levels. A low-GI diet has been shown to effectively help manage PCOS symptoms by improving insulin sensitivity, even for individuals who do not need to lose weight.2 Therefore, switching over to some lower GI options may be beneficial, such as oats, fruits and vegetables, nuts and seeds, beans and pulses, granary bread, sweet potato and wholegrain rice. It is also important that low-GI advice is in combination with a healthy balanced diet, this is because some low-GI items are still high in fat, added sugar and calories and also because the GI can be affected by other nutrients within our diet. Low-carbohydrate or ketogenic diet (KD) There are a few studies to suggest that a reduced carbohydrate or KD can improve insulin sensitivity in PCOS.9-11 However, these studies have small participant groups and have only

provided short-term results to date. If a patient wishes to reduce their carbohydrate intake, it is still important to promote a nutritionally balanced and adequate diet. It can be more difficult to obtain enough fibre on a lowcarbohydrate or KD. A lack of fibre can result in patients with PCOS becoming constipated, which reduces their ability to remove excess oestrogen. If oestrogen and insulin levels are raised, this can increase testosterone levels further.6 Therefore, managing constipation is also vital in PCOS. Mediterranean diet A Mediterranean diet is another popular option for weight management and reducing hyperinsulinemia. It has been associated with increased adherence and reduced central adiposity and insulin resistance.12 This particular approach consists of consuming natural wholesome unprocessed ingredients. Additionally, the carbohydrate containing foods it promotes are typically lower in GI. A Mediterranean diet also encourages relaxed mealtimes, socialising and exercise. EXERCISE

Healthcare professionals should highlight the importance of being physically active. Exercise has been shown to reduce androgen levels and improve lipid profile, blood pressure, weight management, insulin sensitivity, regularity of menstrual cycles and mood for individuals with PCOS.6,3 The aim is a minimum of 150 www.NHDmag.com February 2020 - Issue 151

CONDITIONS & DISORDERS Table 2: Tips to help improve sleep15,16 Avoid alcohol close to bedtime

Keep well hydrated

Exercise regularly, but not directly before bedtime

Avoid late night large meals or snacking

Stop or reduce smoking

Sleep in a dark, cool room

Wear loose fitting clothing in bed

Create a restful environment

Avoid screens close to bedtime

Have a regular sleeping pattern

Relax before bed

Avoid napping during the daytime

Remove pets from the bedroom

Exposure to natural light first thing in the morning

Avoid/ limit caffeine after lunchtime

Relaxation exercises before bed

Take warm baths before bed

Listen to relaxation CDs or soothing music

minutes/week of moderate intensity physical activity (or 75 minutes/week of high intensity), including muscle strengthening activities twice per week.8 Incorporating resistance exercise is very important in PCOS, as increasing muscle mass can improve insulin sensitivity.13 However, healthcare professionals should advise against excessive exercise, as this can increase stress and circulating cortisol levels. Higher cortisol levels can heighten insulin resistance.14 QUALITY OF LIFE (QoL) AND STRESS

Unfortunately, research shows that there is a higher prevalence of anxiety, depression, eating disorders, sexual and relationship dysfunction and a reduced QoL in individuals with PCOS.1 High levels of stress can have a significant impact on insulin resistance and body composition. Therefore, it is important that healthcare professionals routinely screen for psychological issues and offer support. This support may involve referrals to trained professionals, counselling sessions, signposting to local support groups and charities. Additionally, it is important to provide advice to help manage stress, such as exercise, meditation, yoga, socialising, breathing exercises and sleep management. SLEEP

Poor sleep quality, or duration, can also have a detrimental impact on insulin resistance. Therefore, providing the advice outlined in Table 2 may be beneficial. It is also important to be aware that for individuals with both PCOS and sleep apnoea, Continuous Positive Airway Pressure (CPAP) treatment can improve insulin resistance.1 46

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VITAMIN D

Vitamin D deficiency has been shown to be common in individuals with PCOS. However, there is limited evidence to say that supplementation will improve associated symptoms.6 Despite this, it is important for adults to have an adequate vitamin D intake to reduce the risk of osteomalacia. All adults in the UK should consider taking a daily supplement containing 10 micrograms of vitamin D, especially during the autumn and winter months. However, if they are at greater risk of deficiency, then this supplement should be taken all year around.17 SUMMARY

Lifestyle advice is essential for all women with PCOS to help manage symptoms, improve insulin sensitivity and reduce the risk of associated health conditions. Weight loss is important where appropriate; however, positive diet and lifestyle changes can help irrespective of an individualâ&#x20AC;&#x2122;s weight. There is currently no conclusive evidence to suggest one particular type of diet is the most beneficial. Despite this, the use of a lowGI, reduced carbohydrate or a Mediterranean dietary approach could be successful. Dietary methods should also include advice to help avoid or manage constipation. Exercise, including both cardiovascular and resistance, is also important in the management of PCOS. However, healthcare professionals should encourage patients to avoid both excessive exercise and extreme diets. The impact of sleep and stress management should not be underestimated and regular screening for health complications and psychological issues is vital.

NUTRITION MANAGEMENT

ORAL NUTRITIONAL SUPPORT IN EATING DISORDERS Oral nutritional support in the form of sip feeds is an integral part of dietetic practice, used to supplement dietary intake and support weight gain in individuals who struggle to meet their nutritional requirements. This article provides an overview of the use of sip feeds and the considerations required. Eating Disorders are complex mental health illnesses, with the individual often experiencing anxiety, low mood, low self-worth and weight and shape concerns. This is coupled with behaviours around food, including restrictive eating and/or binge eating and compensatory activities. Eating disorder services commonly treat a variety of diagnoses, including anorexia nervosa, bulimia nervosa, other specified feeding or eating disorders and Avoidant Restrictive Food Intake Disorder (ARFID). It is common practice in a specialist eating disorder unit (SEDU) setting for clients to be offered sip feeds to support managing their prescribed diet if they are struggling to either eat a specific meal or snack, or are finding the volume of food required too difficult. A FOOD-FIRST MODEL

Specialist eating disorder units will have a clear prescribed meal plan for every individual being treated. This is often based around average portion sizes, with snacks and puddings included to promote weight gain. These meals are often offered for a set period of time, where the individual who has an eating disorder is supported by staff from the unit to complete the food. The expectation is that the client finishes their prescribed meal plan every day.

This food-first model is important, as individuals with eating disorders have a complex relationship with food and have often practiced restrictive behaviours and avoidance with their dietary habits. This food-first model is designed to offer exposure to food that might have been avoided for some time due to the eating disorder rules. It also aims to provide normalisation of regular dietary intake and improved eating patterns, to help create success at discharge.1 However, for some individuals, managing the meal might not be possible. This could be due to a mixture of complex psychological and physiological reasons, for example: high level emotional distress like anxiety, long-term avoidance of solid food and significant gastrointestinal discomfort.2 Given the high risk of medical complications that eating disorders pose, meeting nutritional requirements for refeeding and weight restoration is essential. This is where the use of sip feeds becomes important. Alongside refeeding risk, long- and short-term poor health outcomes, rigidity of thinking patterns and behaviours and decreased emotional resilience become more prevalent following significant restriction and weight loss. So, it is important to support the individual to meet their nutritional requirements and start weight restoration.3

Alexia Dempsey Specialist Dietitian and Cognitive Behavioural Therapist Alexia has nine yearsâ&#x20AC;&#x2122; experience as a dietitian in eating disorders. She currently works at the Schoen Clinic and Priory Group, as well as in CAMHS clinics for ED inpatients and adult outpatient.

REFERENCES Please visit the Subscriber zone at NHDmag.com

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WHEN CALORIES COUNT AND SO DOES TOLERANCE

PER 5

ml 00

kcal

Protein

760 21g

Fibre

2.5g

NUTRINI PEPTISORB ENERGY The energy dense peptide feed designed to meet higher nutritional requirements in children from one year of age.

Extensively hydrolysed 100% whey protein Energy dense Excellent compliance* Excellent GIâ&#x20AC; tolerance* Easy to use, convenient and well accepted* This information is intended for healthcare professionals only. Nutrini Peptisorb Energy is a Food for Special Medical Purposes for the dietary management of disease related malnutrition in children from one year onwards with malabsorption and/or maldigestion, and must be used under medical supervision. Accurate at time of publication, January 2020.

*Data on file (2016). ACBS trial, n=(7), Nutricia Ltd. â&#x20AC; Gastrointestinal

NUTRITION MANAGEMENT Figure 1: ONS as nutrition pathway

There is no consensus on how sip feeds should be calculated, with units having their own protocol dependant on staff experience. Some units will replace calorie for calorie; some will offer a set amount of replacement for that meal (i.e. a quarter of lunch not eaten is equal to x amount of mls of sip feed); and some will offer in fractions of completed meal (i.e. if less than half is managed, the whole meal will be replaced using sip feed). VOLUME AND QUANTITY

The tolerance of sip feeds will be client specific and the types used will come down to a specific service and the individual receiving treatment. For the individual who has been significantly restricting their dietary intake in quantity, they may experience heightened sensitivity to fullness, which could result in increased anxiety, distress and gastrointestinal disturbance, or perceived gastrointestinal disturbance post meal. So, a high-energy low-volume feed may be tolerated better. For an individual struggling to meet fluid requirements, a higher-volume lowerenergy supplement may be preferred. The use of sip feeds including fibre can be helpful for some individuals, to minimise

gastrointestinal complications brought about by refeeding and laxative misuse. BOLUS NASOGASTRIC FEEDING

For some, managing their prescribed meal plan and the oral sip feed is not tolerable. At this point multidisciplinary team discussion can be in support of bolus nasogastric feeding to minimise medical complications. Whilst this is an intervention that involves significant discussion with the client, often including their next of kin and which may involve the use of a legal framework like the Mental Health Act, it can also involve sip feeds. In this instance, the same sip feed, which is offered in the dining room to replace food not managed, can be placed down the nasogastric tube when required. This can support the journey back to normalised eating, providing a transparent nutrition pathway for the individual to understand and follow. VEGAN OPTIONS

With the global shift towards more plantbased eating, veganism has never been more mainstream. Veganism in eating disorders is still approached with caution, as it is often enmeshed with the eating disorder. The British Dietetic www.NHDmag.com February 2020 - Issue 151

NUTRITION MANAGEMENT Association (BDA) Mental Health Group has a peer paper: Practice guidance: veganism and eating disorders,4 which provides information on how veganism within this client group should be managed. At the time of writing, there are currently no completely vegan ONS on the market, with the closest still containing vitamin D from sheep’s wool. For some time now, SEDU’s have been making their own concentrated lipid emulsion ONS like Calogen and Polycal, often using a plant-based milk like Soya. The BDA peer paper suggests using a ‘SlimFast Vitality’ product or ‘Huel’. However, these are advertised as diet products and have added elements like green tea extract, so should be considered with caution and only used under medical supervision.4 OUT-PATIENT SERVICES

Where individuals are in outpatient services, they are often making food choices that are more tolerable and, therefore, are closer to meeting their nutritional needs. However, for some, the use of sip feeds can be supportive as a back-up when emotional distress is high and solid food cannot be tolerated, but also for medicalised weight gain. For some, using a supplement is preferable to eating food as a snack, for example, and can be stopped when the individual reaches a healthy or safe weight. Caution should be exercised, as this can create reliance on sip feeds, with the individual not receiving the same level of support as offered by inpatient units and, so, increasing the risk of dependency on this source of nutrition. A TALE OF CAUTION

Whilst oral nutritional sip feeds can offer a practical and supportive solution, they can lead to individuals with eating disorders becoming stuck and unable to move back to eating real

food. They can encourage patients away from the experience of food, reinforce avoidance of foods and can foster dependency on artificial food sources.1 Eating disorders can crave exactness.5,6 This can come in the guise of calorie counting, macronutrient restriction, rigid rules around timings or presentation of meals. Perfectionism is often a clinical feature of eating disorders. Perfectionism is a desire to achieve unrelenting high standards, alongside self-criticism when these standards are not met. This can mean the individual struggles with managing uncertainty and craves exactness.5,6 Sip feeds can help meet that need for certainty and exactness in a way that food products and prepared meals cannot. Their synthetic nature and precise mix of carbohydrate, protein, lipids, vitamins and minerals mean that they can offer something varied, when eating cannot. However, sip feeds should be used in a timelimited manner and with professional support. One-to-one dietetic intervention, or talking therapy to explore goal setting and motivation for change, is integral to supporting transition back to foods. Mealtime coaching around those goals can help reduce longer-term reliance on these products. CONCLUSION

This is an area with little research, where teams take a differing approach based on clinical experience and client need. Sip feeds can provide a vital resource to promote nutritional stability and weight restoration, but should be approached with caution due to the nature of eating disorders. Their use should be in conjunction with regular support to the individual using them, in order to promote the return to normal eating behaviours and patterns and to minimise avoidance of food.

dieteticJOBS.co.uk To place an ad or discuss your requirements please call

01342 824 073 50

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FOOD AND DRINK

DOES GREEN TEA LIVE UP TO THE HYPE? Green tea is often touted as a ‘superfood’ which has numerous health-boosting qualities. However, there is no such thing as a ‘superfood’, as all foods have positive and negative qualities in different contexts. This article will examine the specific health claims related to consuming green tea. All types of tea, including green tea, are made using the Camellia sinensis leaf. However, green tea leaves are steamed and pressed soon after harvest, whereas black tea leaves are withered then oxidised before being dried, which changes the flavour and nutritional content of the leaves.1 There are many different types of green tea, which differ depending on the region they are from and how they have been produced (see Table 1). NUTRITIONAL CONTENT

All types of tea contain polyphenols, which are thought to confer health benefits by acting as antioxidants and preventing damage to our cells.2 Green tea tends to have higher levels of polyphenols than other types of tea, as the levels of polyphenols reduce during the oxidisation process while producing black tea.3 It is estimated that polyphenols make up roughly 35% of the dry weight of green tea leaves, most of which belong to a group of polyphenols called catechins. The main catechin found in green tea is called epigallocatechin3-gallate or EGCG.4 Other types of polyphenols found in green tea include

theaflavins, thearubigins, quercetin, gallic acid and chlorogenic acid.3,4 Green tea also contains B vitamins, folate, potassium, manganese, magnesium, caffeine and an amino acid called L-theanine, which is thought to make us feel relaxed.3,4 It has been found that in order to extract the most benefit from the active ingredients found in tea, it should be brewed in boiling water for 30 seconds, followed by microwaving for one minute.5 This is because brewing tea for longer releases more nutrients from the tea leaf. GREEN TEA AND CONDITIONS

Heart disease There is quite good evidence that consuming green tea (both as tea and in supplement form) lowers total and LDL cholesterol for people who have high cholesterol levels.6 However, green tea hasn’t been found to affect HDL cholesterol or triglycerides levels.6,7 Green tea has also been seen to help lower systolic blood pressure by 2.08 mmHg, and diastolic blood pressure by 1.71 mmHg.7 This impact was seen to be strongest in those who have high blood pressure (defined as systolic blood

Maeve Hanan UK Registered Dietitian Freelance Maeve is a Consultant Dietitian and Health Writer. She also runs the blog Dietetically Speaking.com, which promotes evidence-based nutrition and fights nutritional nonsense. dieteticallyspeaking DieteticSpeak

REFERENCES Please visit the Subscriber zone at NHDmag.com

Table 1: Types of green tea Gunpowder tea (China)

Sejak (Korea)

Dragon’s Well (aka, Lung Cheng, or Longjin – China)

Sencha (Japan)

Bi Luo Chun (aka, Pi Lo Chun – China)

Kukicha (aka, twig tea, or bōcha - Japan)

Ujeon (Korea)

Matcha (Japan) www.NHDmag.com February 2020 - Issue 151

FOOD AND DRINK pressure measurement of ≥130mmHg), and when green tea was consumed in supplement form. A meta-analysis from 2009 also found that consuming three cups of either green or black tea per day reduced the risk of an ischaemic stroke by 21%.8 However, these results were based on observational studies and the authors highlight that, ‘a randomised clinical trial would be necessary to confirm the effect’. There is also a possible link between consuming green tea and a reduced risk of coronary artery disease, although more research is needed to investigate this.9 Diabetes Green tea is sometimes promoted as a way to prevent and treat diabetes. Although some studies have found a link between drinking tea and lower fasting blood glucose levels, there isn’t enough evidence to say whether drinking green tea or taking green tea supplements is useful for the prevention or management of Type 2 diabetes.10,11 Cancer Research is conflicting when it comes to whether consuming green tea is associated with a reduced risk of cancer. There is some evidence in Asian populations that drinking three to five cups of green tea per day is associated with a lower risk of liver, prostate and lung cancer.16,17 Evidence is more conflicting in terms of oesophageal, colon, rectal, gastric and pancreatic cancer.16 A Cochrane review from 2009 concluded: ‘There is insufficient and conflicting evidence to give any firm recommendations regarding green tea consumption for cancer prevention… If not exceeding the daily recommended allowance [of three to five cups of green tea per day], those who enjoy a cup of green tea should continue its consumption. Drinking green tea appears to be safe at moderate, regular and habitual use.’16 Liver disease There is an association between consuming green tea and a lower risk of liver disease, including fatty liver disease, hepatitis, liver cirrhosis, hepatocellular carcinoma, and chronic liver disease.24 However, this research mainly 52

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applies to the Chinese population and there is a lack of randomised controlled trials in this area. Furthermore, there have been some reports of severe liver damage related to taking specific green tea supplements (as discussed below). Weight management The caffeine and catechins found in green tea may increase energy metabolism slightly and increase fat burning, whilst reducing fat absorption and appetite.4,12 However, these mechanisms don’t always translate into significant weight loss. For example, studies have found that the use of green tea extract results in small and insignificant weight loss, such as 400g to 1.3kg weight loss over three months.13,14 In these studies, weight loss tends to be associated with green tea supplements that also contain caffeine.15 BENEFITS FOR AGING?

A recent meta-analysis of observational studies found that drinking two cups of green tea per day was associated with a reduced risk of cognitive disorders, such as cognitive decline, dementia and Alzheimer’s disease.18 Epidemiological studies have also found an association between green tea and a lower risk of osteoporosis and fractures in elderly women and men.19 This is thought to be related to the polyphenols and fluoride found in green tea, which may improve bone mineral density and support the activity of the osteoblast cells involved in forming new bone. This is an interesting area, but more robust studies are needed. Lab and animal studies have found that applying polyphenols found in green tea topically onto the skin can reduce and repair damage and inflammation in the skin caused by UVB rays.20 There is also some evidence that green tea polyphenols can reach the skin when they are consumed by humans.20 One controlled study found that taking green tea supplements was associated with improved skin outcomes (improved UV protection, skin elasticity, hydration, blood flow, oxygen saturation, skin density and reduced transepidermal water loss).21 However, other studies have found no positive impact from using green tea supplements.22,23 Therefore,

. . . green tea leaves are steamed and pressed soon after harvest, whereas black tea leaves are withered then oxidised before being dried, which changes the flavour and nutritional content of the leaves.

more robust research is needed to see whether consuming green tea, or using green tea supplements is beneficial for skin health. THE SAFETY OF GREEN TEA

As green tea contains caffeine (which is a stimulant), consuming large amounts of it can cause trouble sleeping, anxiety, irritability and frequent urination. Matcha from Japan could potentially interfere with Warfarin medication, as it is very high in vitamin K, whereas this is much less likely to occur with brewed green tea as it is less concentrated than matcha.25,26 It has been found that consuming green tea extract supplements with meals can reduce the absorption of non-haem iron (i.e. iron from plant sources rather than meat), but more research is needed to see if this has any overall negative impact on health.27 There have been some reports of severe liver damage related to the use of green tea supplements. For example, in October 2018, an American man underwent an urgent lifesaving liver transplant, as a result of taking green tea supplements.28 The risk of liver damage seems to be highest when taking multi-ingredient products, or taking green tea supplements on an empty stomach, as this can lead to dangerously high levels of catechins in the blood, which may have a toxic effect.29 It may also depend on genetics as to whether individuals are at risk of liver damage from

these supplements.29 Drinks brewed from green tea leaves are not seen to have the same damaging effects as green tea extracts, as these extracts contain much more concentrated levels of catechins.29 The European Food Safety Authority (EFSA) recently reviewed the safety of green tea and green tea supplements and concluded: â&#x20AC;&#x2DC;Catechins from green tea infusions and similar drinks are generally safe. When taken as food supplements, however, catechin doses at or above 800mg/day may pose health concerns.â&#x20AC;&#x2122;30 CONCLUSION

Green tea is high in polyphenols which are associated with health benefits such as lowering total cholesterol, LDL cholesterol and blood pressure. However, some of the health benefits of green tea are overstated. For example, green tea should not be promoted as a treatment for diabetes or cancer. In terms of weight management, there is no evidence that green tea promotes significant weight loss. There is some interesting research related to the potential role of green tea in reducing the risk of other diseases, cognitive disorders, liver disease, osteoporosis and certain types of cancer; but more research is needed to explore these possible associations. Overall, green tea is a healthy drink for most adults to have, but high dose green tea extracts or supplements can be risky. www.NHDmag.com February 2020 - Issue 151

F2F

FACE TO FACE Ursula meets: PAULINE EMMETT Nutritionist on the ALSPAC study Senior Research Fellow, University of Bristol Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. Ursula enjoys the gifts of Aspergers.

Ursula meets amazing people who influence nutrition policies and practices in the UK.

A previous F2F interviewee, selfeffacing and too modest, suggested to meet up with Pauline Emmett, telling me that, “She is the real expert.” All my F2F interviewees are experts in their fields, but I must say I am privileged to be able to share Pauline’s thoughts on her career and her nutrition insights. Pauline greatly enjoyed science at her mixed grammar school in Newquay in Cornwall. How did love-science turn into study-dietetics, I asked? “Maybe it was doing the nutrition badge on a St John Ambulance course,” she answered. Her interview at Queen Elizabeth College London went well and Pauline was lucky to be offered a full grant. The famous Professor John Yudkin was the head of department and Pauline attests to him being an inspiring lecturer. “The first year of the course was really difficult, and most of the content was basic theoretical science. At 18 and alone in London, I was also a bit overwhelmed. But the more applied aspects of nutrition later in the course were wonderful,” enthused Pauline. She obtained her degree in nutrition and then completed her diploma in dietetics in 1970. Her first dietetic post was in the Windsor and Slough district. Marriage pulled her over to Bristol, where she worked as a dietitian at the Bristol Royal Infirmary, and then became Acting (but not remunerated) Chief Dietitian. The appearance of a baby made full-time employment impossible, but the now-famous gastroenterologist

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Dr Ken Heaton needed a 12-hours-aweek dietitian, and he even organised the 12-hours-a-week childminder! “He was kind and talented and a great teacher: I learnt everything about research through him,” said Pauline. Dr Heaton was very interested in diet and Crohn’s disease, and the particular effects of sugars and fibre. “At the time, we used radio-opaque pellets to measure intestinal transit time and I remember collecting stool samples to be frozen and then X-rayed. On another occasion, I baked identical scones using either fine-ground or coarse ground wheat, to assess differences in glucose metabolism.” In 1990, Dr Jean Golding was planning the definitive study to assess links between diet during pregnancy and later health and growth in children. The Avon Longitudinal Study of Parents and Children (ALSPAC) was also known in Bristol as the ‘Children of the 90s’ study. It has become the fertile pool from which to trawl data on the health effects of fish and other foods. Dr Golding needed a nutrition expert to advise particularly on the development of dietary collection data and Pauline was delighted to join this project. “Young researchers cannot imagine how slow and complicated collection of data used to be (compared to the ‘press a button’ methods of today),” said Pauline. Between 1991-92, more than 14 thousand week-32 pregnant women completed very detailed food frequency

F2F

PUBLIC HEALTH

“Young researchers cannot imagine how slow and complicated collection of data used to be (compared to the ‘press a button’ methods of today),” . . .

questionnaires. Further assessments of the resulting child were made when they were aged 4, 8 and 18 months and then at 7, 10 and 13 years. Of course, technological systems developed in parallel to the study, and Pauline had the particular advantage of having a computercapable husband, who was able to produce a nutrient calculation programme that perfectly matched her requirements. There have been hundreds of scientific publications pulled out from ALSPAC data. I asked Pauline to choose the plum observation. “Eating fish is healthy for mother and child, especially during pregnancy. This could be because of long-chain omega-3 fatty acids. This could be because of iodine. This could be due to other fishy factors. In any case, concerns over possible heavy metal contamination of some types of fish should be downplayed, over the many proven benefits of fish eating.” Pauline has also researched the behaviours of fussy eating in childhood. She contributed to a European Commission project, HABEAT, which determined factors and critical periods in food habit formation in early childhood. “Children should be introduced to lumpy foods in early weaning, rather than just being fed super smooth sweet purees. And eating with adults, to allow parental modelling of enjoyment of varieties of foods, is very beneficial, as opposed to being fed from jars in glorious isolation from adult food consumption,” said Pauline. Parents quickly become very worried about picky eating, but these toddlers are not usually

underweight, and it is important to prevent food eating becoming a parent-child lever of power. In 2004, Pauline obtained her PhD ‘by publication’ on the diets of young children. I wondered whether having a higher degree really mattered to someone who had had such a long career at the heart of research? I was surprised that Pauline was so insistent that it mattered greatly, especially if you worked with academia. “You get respect,” said Pauline, which made me feel sad; that was surely always the case for this amazingly talented nutrition researcher. Pauline confesses to being semi-retired but enjoys being the examiner to many MSc and PhD projects on nutrition and epidemiology, which allows her travel and keeps her on the current edge of research. She is also currently on a review panel of the European Food Safety Authority (EFSA), assessing the upper limits of sugar intakes, which allows her travel to Parma in Italy several times a year, as well as supporting her deep dive into the literature of total/free sugars data. The report of the public consultation on the upper levels of sugars has been delayed to late 2020 due to the volume of data needing to be assessed, and I am sure Pauline is working hard on this. We look around us as the crowds of sugarmunching snackers pass our café table. “That is what there is more of today. Food frequency,” said Pauline. And I had to smile that this was the word (two words) for the start and the end of her research career. www.NHDmag.com February 2020 - Issue 151

A DAY IN THE LIFE OF . . .

A DIABETES SPECIALIST DIETITIAN Working in a dual role in both a hospital outpatient diabetes service and integrated community diabetes service (ICDS) offers plenty of opportunities for dietetic input, multidisciplinary team (MDT) working and patient and healthcare professional education.

Rose Butler RD Diabetes Specialist Dietitian Rose has been a Diabetes Specialist Dietitian for six years and is currently based at Luton and Dunstable University Hospital. She has previous experience in Community and Public Health Dietetics.

Monday always starts with the weekly MDT insulin pump clinic. Insulin pump therapy is also known as continuous subcutaneous insulin infusion (CSII) therapy. The clinic, for patients with Type 1 diabetes, is staffed by a consultant diabetologist, diabetes specialist nurse (DSN) and a diabetes specialist dietitian. Before clinic starts, I check to see if any of our pump patients have contacted the team over the weekend, as we also offer â&#x20AC;&#x2DC;virtualâ&#x20AC;&#x2122; clinics, providing advice via email and telephone on insulin pump-related queries. Today, there is a variety of people to see, from those who are established on insulin pumps and self-managing their pump care well, to others who are currently finding their diabetes self-management more challenging for a variety of reasons. One of today's patients uses MDI (multiple daily insulin injection) therapy to manage his diabetes and asks whether or not he would meet the clinical commissioning group (CCG) criteria to enable him to transfer to CSII therapy. He has already done some research and is keen to find out more. We show him the available pumps, discuss his expectations and explain what pump therapy will require of him. At the end of the face-to-face clinic, the team review the virtual clinic downloads and contact those patients with suggested advice. After lunch, I update our insulin pump database and order a new insulin pump for a patient who has met their CCG's target for continuation of insulin pump funding. I contact her to arrange an appointment once the pump arrives, so that she can learn how to use the newer model. Then I see a pregnant

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lady referred by the Diabetes Specialist Midwife (DSM). The patient was initially thought to have gestational diabetes (GDM) but has now been told that she has an atypical presentation of Type 2 diabetes. A diagnosis of either latent autoimmune diabetes in adults (LADA) or Type 1 diabetes needs to be eliminated, so further blood tests have been requested. I spend some time listening to her concerns and discussing how she can manage her diabetes while pregnant. TWO CLINICS

The community ICDS service is moving towards the care planning model of working. During the transition period, we continue to run some community clinics for patients living with Type 2 diabetes. These are a mixture of joint DSN/dietitian and individual DSN or dietitian-only appointments. At a joint community diabetes clinic held at a local GP surgery, I see a man with Type 2 diabetes who commenced glucagon-like peptide-1 (GLP1) therapy three months ago. GLP1 therapy is a noninsulin injectable medication prescribed to help reduce blood glucose to target levels. It is usually only prescribed for those who have a body mass index (BMI) in the obese category as GLP1 therapy can have a sideeffect of reducing appetite. The patient tells me that he is remembering to give his weekly GLP1 injection and his blood glucose diary shows improved readings. He is also pleased to learn that he has lost some weight. We discuss further changes that he could make to support continued weight loss. In the afternoon, I cover a short preconception clinic for women with Type 1 diabetes for a colleague who

GESTATIONAL DIABETES EDUCATION

I give advice on safe dietary and lifestyle changes to help with management of blood glucose levels in pregnancy.

EX-WARD CLINIC

One of today's patients was diagnosed with Type 1 diabetes at his recent admission. This is his first outpatient appointment since going home. He admits that the whole experience has been a shock and that he felt overwhelmed with all the information that he has received. We reassure him that although there seems a lot to learn, the team are here to support him with as much or as little advice as he needs for as long as he wishes us to. I show him some pictures and models of food and drinks containing carbohydrates to continue his education surrounding carbohydrate. I briefly discuss how to interpret food labels. As all carbohydrates raise blood glucose levels, I explain that the total carbohydrate (carbohydrate + any sugars) amount in his portion is important. We arrange separate follow-up appointments with both the DSN and myself and I suggest that he might like to attend our carbohydrate counting patient education session.

is on annual leave. I discuss timing of insulin doses and carbohydrate portion sizes with one lady and explain the NICE guidance to aim for an HbA1c of ≤48mmol/mol before conception “if achievable without causing problematic hypoglycaemia” to another. I also share teaching of a group for women newly diagnosed with GDM with a diabetes assistant practitioner (DAP). I prepare the room, set out the visual aids and welcome the women one by one, as I measure their height and weight. There are often partners, occasionally a young child and sometimes interpreters in the group as well, so it can be quite a challenge to successfully facilitate the teaching with so many different individuals present. I give advice on safe dietary and lifestyle changes to help with management of blood glucose levels in pregnancy. While the DAP shows the women how to use a blood glucose monitor, I complete my entries in the women's maternity notes, allocating their follow-up appointments in next week's dietetic GDM clinic. The DSM arrives at the end of the session to explain the potential risks from GDM to mother and baby. She details the extra appointments and scans that the women will now need to attend. When it's my turn to run the ex-ward clinic with a diabetes inpatient specialist nurse (DISN), we see a variety of patients who were recently discharged home. They may have been admitted with either Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycaemic State (HHS), or might have commenced insulin therapy during their stay. The DISN checks that the patient understands correct insulin injection technique and assesses their blood glucose diary and diabetes medication. I discuss the diet and lifestyle aspects of diabetes care, especially healthy eating and carbohydrate awareness. Both the DISN and I may also address other aspects of diabetes and insulin care, such as structured education, correct disposal of sharps, DVLA guidance, hypoglycaemia treatment and the importance of attending retinal screening.

CARER TRAINING

Diabetes training sessions for carers who work at a local residential care home are rewarding sessions to deliver. It’s another opportunity to make good use of food models and other resources to illustrate various points. I never tire of showing people just how much sugar there is in a bottle of Lucozade! At the end of the care home training session, one of the senior carers asks for advice about a resident who has raised blood glucose levels. I'm able to offer some initial guidance and suggest that the carer phones the home's allocated community DSN. Working in both the outpatient diabetes service and ICDS, my days are full, challenging, but satisfying. I wouldn’t have it any other way! www.NHDmag.com February 2020 - Issue 151

EVENTS & PUBLIC HEALTH COURSES THE ROYAL MARSDEN FOUNDATION TRUST BRINGS YOU THE FOLLOWING EVENTS IN 2020: 10th Mar 2020: Nutrition and Cancer Myths - EVENT ID 809 12th Mar 2020: Foundation in Oncology for Speech and Language Therapists EVENT ID 680 8/9th Sep 2020: Swallowing and Communications Rehabilitation Course (2-day) EVENT ID 864 For more information click here . . .

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

MATTHEW’S FRIENDS – KETOCOLLEGE PROGRAMME The 5th annual KetoCollege programme for Medical Ketogenic Dietary Therapy learning and networking 12th-14th May 2020 Crowne Plaza Felbridge, East Grinstead – less than 1 hour from London, 20 mins from Gatwick airport For more information visit: www.mfclinics.com/keto-college/ketocollege-uk-2020/

IRRITABLE BOWEL SYNDROME – DIETETICS MANAGEMENT AND SYMPTOM CONTROL 12th Feb 2020 BDA Trainer – Amanda Avery Venue: London Road Community Hospital, Derby www.ncore.org.uk EATING DISORDERS AWARENESS WEEK 2nd-8th Mar 2020 www.beateatingdisorders.org.uk/edaw

THE ALLERGY AND FREE FROM SHOW SCOTLAND 2020 7th-8th Mar 2020 For more information click here . . . CHALLENGES OF NON-MEDICAL PRESCRIBING IN A CANCER POPULATION 9th Mar 2020 Royal Marsden Study Day For more information click here . . .

dieteticJOBS.co.uk

01342 824073 BAND 7 PAEDIATRIC TEAM LEAD DIETITIAN SALARY- £37,570 – £43,772 We have an opportunity for a skilled paediatric dietitian to inspire and lead the paediatric service at Medway Hospital. This is a great time to join Medway NHS Foundation Trust during a period of transformation and improving clinical services, where the Trust is investing in nutrition as a priority. We are recruiting a Paediatric Dietitian who has a passion to provide excellent care to our patients and shares our ambition and vision to deliver the Best of Care by the Best People. The ideal candidate will have the drive to take us forward, by ensuring that

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the Trust continues to be the first choice for patients and our staff. The post is for a highly specialist dietitian working within the paediatric multi-disciplinary team to provide a service to paediatric inpatients, neonatal unit and clinics including cystic fibrosis and allergy. For informal enquiries, please contact Amelia Lythgoe or Helen Hume, Clinical Lead Dietitians on: 01634 833848. Email: amelia.lythgoe@nhs.net or helen. hume@nhs.net Closing date: 11th February.

FOOD AND THREE KIDS . . . THINGS CHANGE I am coming to the end of my third maternity leave (I still sometimes can’t believe I am writing that) and reflecting on the past year, being a mother of three children. I have been through the weaning journey again and have been considering juggling going back to work and ensuring my brood eat a healthy diet. We are all well into a new year and are hopefully keeping up with any healthy changes and new healthy habits, which makes me think back to my food mindset after having my first baby. I sometimes feel being both a mother and a dietitian can be a slight hindrance, as there is a constant internal panic that my kids need to have a perfectly balanced diet. This is always worse with your first child: the desire for perfectly composed meals ensuring a mix of protein, carbohydrates and fat. I made sure my baby girl ate salmon once a week, she snacked only on fruit and pudding was plain yoghurt for a long time. She followed this diet well until fussiness kicked in and she went off all fruit and developed an affinity for chocolate buttons! My attitude towards food has changed so much since I have had my second daughter and finally my son. Food is no longer something that needs to cause me stress as a mother. I’ve relaxed a lot more. We don’t tend to cook separate meals for the baby and as long as I watch the salt content, all three can usually have the same thing. This means we throw less away. Leftovers from a roast are perfect for another day for my baby boy. I don’t worry as much if my eldest want’s something simple

when she comes home from school; quite often her favourite choice is a fish finger wrap with peas and sweetcorn. It’s balanced and she’s had a hot meal at school. I don’t panic if the girls want something sweet after their tea, if I know they have had fruit and proteinrich snacks earlier on and eaten their main meal. When my first daughter was ill and refused food, this was such a worrying time, but I have learnt that young children eat so intuitively; they listen to their bodies. If they feel poorly their instinct is not to eat. When they are well, they make up for it and their usual healthy diets return. I’ve witnessed this happen many times. It is hard not to feel pressured with children and their meals. Social media is littered with plates of perfect food! But I often find simplicity works and think about what they eat over a week, not a day. My kids know I am quite strict with healthy eating, but we have found a way to ensure they stay healthy whilst also having some choice, so we all stay happy too. It has taken me six years to relax a little as a mother and a dietitian when it comes to my children’s diets. I wonder where I will be in another six years!

Sarah Howe Specialist Dietitian Sarah is an experienced NHS Dietitian specialising in the fascinating area of Inherited Metabolic Disorders in adults. In her spare time she enjoys helping her work colleague and good friend, Louise Robertson run her blog 'Dietitian's Life'. She also loves fitness and spending time with her two girls. www. dietitianslife.com

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Coming in the March issue:

• Follow-on formula • Critical care/ICU nutrient management • Diabetes nutrition and management • Malnutrition: 'MUST' assessment • Ketogenic diet therapy • Food allergies in adults • Nutrition and hydration • Mindfulness in dietetics _______ Check whether you are eligible for a FREE subscription to

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