Network Health Digest Dec/Jan 2020

S G N M TI EA EE T R G HD ’S N N E SO TH A SE OM FR

The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

TYPE 1 DIABETES IN CHILDREN & YOUNG PEOPLE

HYPOTHYROIDISM MENOPAUSE: DIETARY ADVICE GUM-BASED THICKENERS BONE HEALTH MDT WORKING PKU THROUGH LIFE WEIGHT MANAGEMENT IN PUBLIC HEALTH

HIV & nutritional care: Pages 16-19

Dec 2020/Jan 2021: Issue 159

NEW

HEAVY ON PROTEIN LIGHT ON THE GUT Nutrison Peptisorb Plus HEHP is a new peptide-based option for tube-fed patients with GI intolerance symptoms. The high energy, high protein formulation has been shown to improve patients’ tolerance, increase their compliance and may even help to lighten their mood.1

1. Nutricia ACBS trial, data on file 2020.

Accurate at time of publication, June 2020.

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Nutrison Peptisorb Plus HEHP is a Food for Special Medical Purposes for the dietary management of disease related malnutrition in patients with malabsorption and/or maldigestion and must be used under medical supervision.

This information is intended for Healthcare Professionals only.

UP FRONT Emma Coates Editor

Welcome to this final issue of 2020. The year that will go down in history as ‘something else’, and I think that’s putting it mildly!

It has been a strange and stressful year for most people, experiencing a huge change in the way we live and work entirely. Our resilience and wellbeing may have been tested to the limit and, sadly, there may have been many casualties along the way. Hopefully, however, there have been successes, achievements and good times too, despite the viral storm we’ve been existing in since the first lockdown in March.

I’m sure you all have your own ways of reflecting on the ‘Coronacoaster’ you’ve been riding, but looking ahead to 2021, we are all hopeful that the new vaccines will be ready to roll out by the spring. Here at NHD, we’ve kept our wheels in motion via remote working and making use of various bits of technology to ensure we stay in touch. Like many of you, we’ve adapted to ensure we get the job done and we continue to develop despite the challenging situation we’re all in. This has included getting to grips with Zoom or Team meetings, and still getting caught out with the mute button! ‘You’re on mute!’, will probably go down as one of the most said phrases in 2020.

This virus and our new normal have given birth to plenty of new phrases and words (I think I’ve used a few of them already in this Up Front column without even thinking about it!) Here are a few

of the strangest words I’ve come across, which have made me laugh: • Quaranbaking – the therapeutic act of baking during lockdown.

• Hamsterkaufing – stockpiling and/or hoarding (adapted from German).

• Blursday – an unspecified day because of lockdown’s disorientating effect on time.

Emma has been a Registered Dietitian for 14 years, with experience of adult and paediatric dietetics. coatesyRD

We’re delighted to say, our features schedule for 2020 has been a huge success, with excellent contributions from new and familiar writers. We’d like to give a big thank you to everyone who’s helped to create all of the great content we’ve published this year. This double issue sees us out of 2020 and into 2021 with a wealth of features, which cross the lifespan, looking at various conditions. Our Cover Story comes from Aisling Pigott and Thomas Coles, two paediatric diabetes dietitians based in Cardiff and Vale University Health Board. Their article focuses on the management of Type 1 diabetes in young children and covers current dietary recommendations and the technology being used in patient care.

Whilst the festive period may not be the same as usual for most of this year, the NHD team would like to wish you all a happy, healthy, low-stress Christmas and New Year. Emma www.NHDmag.com December 2020 / January 2021 - Issue 159

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Order samples* online at:

nutriciasamples.com This information is intended for Healthcare Professionals only.

Fortini Compact Multi Fibre is a Food for Special Medical Purposes for the dietary management of disease related malnutrition and growth failure in children from one year onwards, and must be used under medical supervision. * Product can be provided to patients upon the request of a Healthcare Professional.

They are intended for the purpose of professional evaluation only.

11 COVER STORY Type 1 diabetes in children and young people

News

Latest industry and product updates

6

37 MULTIDISCIPLINARY TEAM WORK

Weight management

Weight-centric health promotion policies

8

16 HIV

Nutritional support for patients

40 IMD watch

25 Hypothyroidism

41 ENHANCED RECOVERY PRE- & POSTOP 44 F2F

Hashimoto’s thyroiditis and nutritional status

PKU in the time of COVID

21 GUM-BASED THICKENERS

Interview with Julie Lanigan

29 MENOPAUSE & DIETARY ADVICE

46 Events, courses & dieteticJOBS

Dates for your diary and online details for NHD resources

47 Dietitian's life

Optimising dietary management

33 Bone health

Goodbye 2020!

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 Annie Hall Columnist Ursula Arens Design Heather Dewhurst

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

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5

NEWS CLINICAL

Emma Coates Editor Emma has been a Registered Dietitian for 14 years, with experience of adult and paediatric dietetics. coatesyRD

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INSULIN RESISTANCE IN CHILDREN: STUDY Type 2 diabetes usually develops in adulthood, but research suggests that its prevention is best begun in childhood. A new study from the University of Eastern Finland1 shows that individualised and family-based physical activity, along with dietary counselling, considerably slows down the development of insulin resistance, a precursor of Type 2 diabetes, in six- to nine-year-old children.

More than 500 Finnish children, predominantly normal weight, participated in the study. Children and their caregivers in the intervention group were given individualised and family-based physical activity and dietary counselling over a period of two years. Children and their caregivers in the control group, on the other hand, were given instructions on physical exercise and nutrition as per the national guidelines, but no actual lifestyle counselling.

At baseline and two years later, the researchers analysed children’s physical activity and sedentary behaviour using the Actiheart sensor that measures heart rate and body movements. Physical activity was also assessed by the PANIC Physical Activity Questionnaire, and dietary factors were assessed by a fourday food record. Children’s body fat percentage and lean body mass were measured by dual-energy x-ray absorptiometry, DXA. Fasting serum insulin and HOMA-IR were used as indicators of insulin resistance.

During the two-year follow-up, increase of insulin resistance was roughly 35% lower in the group that was given individualised and family-based physical activity and dietary counselling than in the control group. The attenuating effect of counselling on insulin resistance was explained especially by changes in physical activity and sedentary behaviour, and slightly less by changes in overall dietary quality and in the consumption of high-fat spreads. Counselling did not have an effect on body fat percentage or lean body mass, i.e. changes in body composition did not mediate the beneficial effect of intervention on insulin resistance.

1 Lakka TA, Lintu N, Väistö J et al (2020). A two-year physical activity and dietary intervention attenuates the increase in insulin resistance in a general population of children: the PANIC study. Diabetologia 63, 2270-2281. https://doi. org/10.1007/s00125-020-05250-0

CAMBRIDGESHIRE ASSISTANT CORONER CALLS FOR SPECIALIST EATING DISORDERS TRAINING A “level of ignorance” among medics about eating disorders needs to change, was the warning from a coroner who has overseen inquests into five anorexia deaths in the past 12 months.1 Sean Horstead, a Cambridgeshire assistant coroner, expressed his concerns following multiple reports about the catastrophic failings in the care of eating disorder patients. He emphasisied the need for specialist training for all who work with eating disorder patients, from healthcare assistants to consultants.

Mr Horstead focused on the need to robustly record the increasing number of anorexia deaths and stressed that whilst each woman’s care journey was a different experience, a common theme was the absence of a “formally commissioned provision” for the monitoring of anorexia sufferers.

Mr Horstead described the current situation as “something of a postcode lottery, describing it as miscommunication between primary and secondary care.

He will be raising his concerns with NHS England, the Royal College of Psychiatrists and the General Medical Council.

1 “Eating disorder services in England need urgent changes,” says coroner BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4346 (Published 09 November 2020)

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www.NHDmag.com December 2020 / January 2021 - Issue 159

DO WE THINK PRETTIER FOOD IS HEALTHIER? A study from Linda Hagen of the University of Southern California in Los Angeles has found that people consider prettier food to be more healthful.1 Hagen tasked 803 participants with finding both “pretty” and “ugly” images of ice cream sundaes, burgers, pizza, sandwiches, lasagne, omelettes, and salads. The participants rated the pretty versions of their foods as being healthier. They did not see tastiness, freshness, or portion size as influencing factors.

In another experiment, participants rated the healthiness of avocado toast. Before viewing images of the dish, individuals received information on the ingredients and price, which was identical for all the examples. Participants who saw images of “pretty” avocado toast rated it as being more natural and also healthier.

Hagen also tested the effect of stimulus bias, presenting 801 people with two identical images of a range of foods varying in healthfulness levels. The foods were almond butter and banana toast, spaghetti marinara and cupcakes. The researchers manipulated the participants to expect either a “pretty” or “ugly” image: Supporting the notion that attractiveness follows natural properties, individuals found the food was prettier when they were expecting an ‘orderly’, ‘symmetrical’, and ‘balanced’ presentation in the image they viewed. Once again, the participants associated pretty foods with being more natural and more healthful. Images of carefully styled foods in adverts and on menus may promise more than enjoyable food. With fast food in mind, Hagen writes: “This finding is disconcerting because a large proportion of visually advertised food is unhealth[ful] food.”

1 Hagen’s L (2020). Pretty Healthy Food: How and When Aesthetics Enhance Perceived Healthiness. Journal of Marketing. https://journals.sagepub. com/doi/abs/10.1177/0022242920944384

DOES RESTRICTING MEALS TO EARLY IN THE DAY AFFECT WEIGHT? A study from Johns Hopkins University in Baltimore, USA has looked at whether restricting meals to early in the day affects the weight of overweight adults with prediabetes or diabetes.1 The study followed 41 overweight adults for 12 weeks. Most participants (90%) were black women with prediabetes or diabetes, and an average age of 59 years. Twenty-one of the adults followed a time-restricted eating pattern, limiting eating to specific hours of the day and ate 80% of their calories before 1pm. The remaining 20 participants ate at usual times during a 12-hour window, consuming half of their daily calories after 5pm for the entire 12 weeks. All participants consumed the same pre-prepared, healthy meals provided for the study. Weight and blood pressure were measured at the beginning of the study; then at four weeks, eight weeks and 12 weeks. The analysis found that people in both groups lost weight and had decreased blood pressure regardless of when they ate.

The researchers are now collecting more detailed information on blood pressure recorded over 24 hours, and they will be compiling this information with the results of a study on the effects of time-restricted feeding on blood sugar, insulin and other hormones.

1 Lakka TA, Lintu N, Vaisto J et al (2020). A two-year physical activity and dietary intervention attenuates the increase in insulin resistance in a general population of children: the PANIC study. https://link.springer.com/article/10.1007/s00125-020-05250-0.

www.NHDmag.com December 2020 / January 2021 - Issue 159

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PUBLIC HEALTH

Leanne Thompson ANutr Freelance Nutritionist Leanne has recently completed her MSc in Nutrition at the University of Aberdeen and has a passion for Infant and Public Health nutrition.

REFERENCES Please visit: nhdmag.com/ references.html

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WEIGHT MANAGEMENT AND PUBLIC HEALTH POLICIES Weight-centric health promotion policies have been highlighted recently due to COVID-19, with slimming clubs offering discounts to people who join via the UK’s ‘Better Health’ campaign. This article considers whether this is the best route for encouraging a healthier population.

Weight reduction has been a public health priority for many years. Now, it is high on the agenda after a report by Public Health England (PHE)1 found people who are obese or excessively overweight are more likely to suffer serious complications from COVID-19.

One study highlighted in the PHE report, found that mortality risk from the virus was 40% higher in people with a BMI of between 35 and 40. This is cause for concern at a time when currently 67% of men and 60% of women in England are classed as overweight or obese.2 In light of these findings, the Government launched its new ‘Better Health’ campaign, encouraging the public to improve their health through three behaviour modifications, one of which is to alter their diet to achieve weight loss.

The campaign, delivered by the NHS, offers a free 12-week weight-loss plan and brings on board commercial slimming clubs including Weight Watchers (WW) and Slimming World. Whilst these clubs require a subscription fee, discounts are on offer for people joining their weightloss plans via the campaign.

Many people do successfully lose weight with these programmes; however, there are many others who do not. Furthermore, people who attempt to lose weight through dieting can suffer from an array of adverse consequences, which raises ethical questions about public health messages that specifically encourage the general public to lose weight either via slimming clubs, or through self-managed calorie-restricted diets.

www.NHDmag.com December 2020 / January 2021 - Issue 159

ETHICAL CONSIDERATIONS

It is well accepted that losing weight and maintaining that loss is difficult for the majority of those who diet, for numerous reasons. It could be argued that if weight loss was easily achievable through dieting, we wouldn’t have such a high proportion of people in this country classed as overweight or obese.

A study3 in 2005, found that only 20% of people who participated in a weight-loss intervention were able to maintain their weight after one year.

This study is not alone in its findings; another study found that up to two thirds of people following a calorierestricted diet regained more weight than they lost.4 Other studies have also highlighted issues with weight gain after calorie-restricted diets.5 If this is a common theme with weight-loss interventions, is it ethical for slimming clubs to charge clients a fee for continued support, knowing that it can be extremely difficult for them to maintain their weight and a reduced energy intake without support? Interestingly, it has been calculated that the subscription fee to participate in the American version of WW, which is part of the US diet industry and estimated to make $58.6 billion annually, costs participants on average $155 to lose one kilogram of weight.6 Encouraging these subscription programmes in England to promote weight loss could be deemed unethical if the weight is likely to be regained.

PUBLIC HEALTH

There is a huge amount of evidence that shows obesity as a risk factor for chronic diseases such as numerous cancers, cardiovascular disease, Type 2 diabetes and respiratory diseases, and that a reduction in weight can lead to positive health outcomes.

Additionally, the majority of slimming clubs are not hosted by registered nutrition professionals (ANutr, RNutr, or RD), but by members of staff trained by the organisation itself. This could risk the dissemination of biased or even inaccurate advice to those attending the clubs.

SHOULD WE BE FOCUSING ON WEIGHT AS A MEASURE OF HEALTH?

There is a huge amount of evidence that shows obesity as a risk factor for chronic diseases such as numerous cancers, cardiovascular disease, Type 2 diabetes and respiratory diseases,7 and that a reduction in weight can lead to positive health outcomes. One meta-analysis8 found an 18% reduction in mortality over two years in people with obesity who had reduced their weight through dieting (mainly a diet low in fat and saturated fat).

There is a considerable amount of evidence supporting the notion that a high BMI is considered a risk factor for ill health; however, this assumes that people with a BMI of >25 have poorer health and that long-term weight loss is attainable and improves overall health.

A reduction in weight does not guarantee improved health or modified health behaviours, and people of a ‘normal’ weight are also at risk

of developing Type 2 diabetes as well as other non-communicable diseases. Furthermore, by using BMI as the gold standard measurement for health, we risk missing diagnoses in people with a ‘normal’ weight. It is also now commonly understood that using BMI as a measurement of health may not be the best model when factors such as body composition and age are not taken into account. Moreover, using a weight-centric approach to health promotion can lead to an increase in weight stigma and bias, which in turn can discourage overweight or obese people to seek healthcare when required.

DIETING COULD DO MORE HARM THAN GOOD

There are various adverse outcomes to dietary restriction and a lack of public discussion around these consequences. Those who do partake in a caloric reduction to achieve a lower weight are susceptible to a number of consequences, such as weight cycling or ‘yo-yo dieting’. Weight cycling – the act of losing and regaining weight – has been linked to many deleterious effects, such as loss of muscle tissue, increased risk of osteoporotic fractures, hypertension and even higher mortality.9 Having a target of weight loss instead of increased health behaviours could also have an adverse effect on mental health.

www.NHDmag.com December 2020 / January 2021 - Issue 159

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PUBLIC HEALTH It has been found that dietary restraint is a predictor for the onset of eating disorders,10,11 which can have lifelong health implications, both psychological and physiological, with the risk of mortality, and can require extensive treatment. A restricted intake of calories is also a risk factor for disordered eating with subsequent episodes of binge eating, which was actually found to be a predictor for onset obesity.12 A NEW APPROACH

A relatively new model that follows a nondiet approach and is being utilised by some healthcare professionals is ‘Health at Every Size’ (HAES). This encourages health improvement behaviours regardless of weight and uses physiological, behavioural and psychosocial measurements instead of BMI to determine health. HAES encourages body acceptance, calls for patient reliance on selfregulatory processes (hunger and satiety cues), and supports an active lifestyle away from rigid exercise schedules.

Studies have found that the HAES approach can improve health, using physiological measurements such as blood pressure and blood lipids, and can increase health behaviours (physical activity and improved eating behaviours).13 Self-esteem was also seen to increase while following the HAES model. Whilst these results are promising and highlight an alternative approach to weight reduction for health promotion, the studies used relatively small samples and more studies

are required. However, this is an exciting ‘weight-inclusive’ approach, which could help many people to improve their health without the need to restrict their diets.

CONCLUSION

It has long been documented and argued that having a ‘normal’ weight, according to BMI classification, is healthy and anything either side of that could have deleterious health implications. This theory is widely accepted by many healthcare professionals; reducing body weight through dieting is often seen as part of the solution to the obesity epidemic. However, it is also emerging that losing weight may not be the best solution.

The idea of improving health on a population level through a weight-reduction approach could be deemed unethical, as the adverse effects of this approach are well documented, and this method is often unsuccessful. Encouraging healthpromoting behaviours inclusive of weight, provides an opportunity to reduce weight bias and stigma, as well as the often undiscussed and unwelcome consequences of dieting, whilst improving the overall health of the population.

Weight-centric health policies may be supported by literature, but isn’t it time to look for alternative approaches in order to limit damaging consequences caused by dieting in a bid for health? Looking at weight loss or health improvement methods on a spectrum rather than through a ‘one size fits all’ prescription may be what’s needed moving forward.

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TYPE 1 DIABETES IN CHILDREN AND YOUNG PEOPLE

COVER STORY

This article focuses on the management of Type 1 diabetes in the young, examining the current dietary recommendations and the technology utilised in patient care.

Type 1 Diabetes Mellitus (T1DM) is a life-threatening auto-immune condition with no known cause, resulting in the death of insulin-producing pancreatic beta cells and absolute insulin deficit.1 The only available treatment for T1DM is exogenous insulin therapy, as injection or continuous subcutaneous insulin infusion (CSII).

T1DM affects 29,000 children and young people (CYP) living in the UK, with more CYP represented in the most deprived quintile areas.2 The incidence of T1DM is increasing annually, particularly in children younger than five years old.2 The physical, practical and psychological burdens of T1DM are important considerations when understanding the condition. Physically, CYP experience fluctuating blood glucose (BG) levels and associated risk of diabetic ketoacidosis, irritating issues such as skin sensitivity and reactions to diabetes technology, including lipoatrophy.

Practically, considerations include high frequency of BG testing, the availability of an appropriate place to deliver insulin, maintaining technology, missing school, social and work commitments to attend appointments.

Psychologically, the burdens of the disease have been measured as equitable or greater than CYP living with cancer or conditions with higher mortality like cystic fibrosis.3-5 Hence, CYP living with T1DM have poorer quality of life (QoL) than their peers without diabetes.

In addition, T1DM is associated with long-term cardiovascular,6 renal and neurological complications.7

A specialist paediatric diabetes team is recommended7 to support CYP and their families to manage T1DM. Structured education, including nutrition and promoting self-management is the cornerstone of paediatric diabetes care, and should be delivered on an ongoing basis.7,8 Dietitians play an essential role in the development, delivery and evaluation of this education.

NUTRITIONAL MANAGEMENT OF TYPE 1 DIABETES

The incorporation of nutritional care improves clinical and metabolic outcomes in the management of T1DM.9 Current dietary management of T1DM promotes the same healthy eating messages suitable for all children and adults.7,10 Although dietary advice may not differ from general public health advice, it is essential that a specialist dietitian with an understanding of paediatric nutrition, socio-demographic status and behavioural issues and, most importantly, insulin and glycaemic responses to food, is integrated within a diabetes MDT. AIMS OF NUTRITIONAL MANAGEMENT IN TYPE 1 DIABETES

1 Adequate and appropriate nutrition for health Promoting appropriate nutritional intake for age, growth and activity levels is a core component of supporting a child and young person living with T1DM.10 Regular meals, high-fibre choices and avoiding unnecessary dietary restriction should underpin dietetic advice and structured nutrition

Aisling Pigott Registered Dietitian Cardiff and Vale University Health Board Aisling is a Paediatric Diabetes Dietitian, with interests including paediatrics and obesity prevention. She is an active media spokesperson and committee member of BDA sub-groups.

Thomas Coles Registered Dietitian Cardiff and Vale University Health Board Thomas Coles is a Paediatric Diabetes and Endocrine Dietitian, with an interest in paediatric Type 2 diabetes. He is a member of the BDA’s Paediatric and Paediatric Diabetes specialist groups.

REFERENCES Please visit: nhdmag.com/ references.html

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INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best

APTAMIL PEPTI SYNEO FOR THE DIETARY MANAGEMENT OF COW’S MILK ALLERGY IN FORMULA-FED INFANTS

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Aptamil Pepti Syneo The only EHF with a unique combination of pre- and probiotics (synbiotics) that work synergistically

Compared to non-synbiotic formulas† Aptamil Pepti Syneo has been shown to support

IMPROVED symptom management1–4 • reduction in abdominal discomfort and wind1 • reduction in atopic dermatitis severity2‡,3 • reduction in constipation1,2 and dry stools2

For further information visit nutricia.co.uk or contact our Healthcare Professional Helpline on 0800 996 1234

PLUS

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m milk allergy. It should only be IMPORTANT NOTICE: Breastfeeding is best. Aptamil Pepti Syneo is a food for special medical purposes for the dietary managementim of cow’s and of nutrition for infants used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the lthsource heasole from birth, and/or as part of a balanced diet from 6 months. Refer to label for details. g-term lon support robiota to ic m t gu s the u Mod late

References: 1. Atwal K et al. An extensively hydrolysed synbiotic-containing formula improves gastrointestinal outcomes in infants with non-IgE cow’s milk protein allergy, already well-established on extensively hydrolysed formula. Poster Presentation. European Academy of Allergy and Clinical Immunology Food Allergy and Anaphylaxis Meeting 2020. 2. Van der Aa LB et al. Clin Exp Allergy.

2010;(40):795–804. 3. Browne et al. A synbiotic EHF may help improve atopic dermatitis-like symptoms and parental QOL in infants with non-IgE mediated cow’s milk allergy. Poster Presentation.

European Academy of Allergy and Clinical Immunology Paediatric Allergy and Anaphylaxis Meeting 2019. 4. Browne et al. A new synbiotic EHF for infants with cow’s milk protein allergy is well tolerated, highly acceptable and supports good growth and intake over 28 days. Poster Presentation. British Society Allergy and Clinical Immunology Meeting 2019. 5. Van der Aa LB et al. Allergy. 2011;66:170–177.

6. Martin R et al. Benef Microbes. 2010;1(4):367–82. 7. Wopereis H et al. Pediatr Allergy Immunol. 2014;25:428–38. 8. Harvey BM et al. Pediatr Res. 2014;75:343–51.

PLUS

* GOS/FOS = Galacto-oligosaccharides and fructo-oligosaccharides. † UK 4 week single split arm study1,3–5: infants with non-IgE mediated CMA, baseline non-synbiotic EHFs vs Aptamil Pepti Syneo.

12 week randomised controlled trial2: infants with atopic dermatitis, Aptamil Pepti Syneo vs Aptamil Pepti. ‡ subgroup of n=48 infants with IgE associated atopic dermatitis.

20-186. Accurate at date of publication December 2020. © Nutricia 2020.

COVER STORY

. . . children living with T1DM are more likely to be overweight or obese than their peers . . .

It is important to balance the message between ‘eating without restriction’ and health promotion messages to achieve appropriate weight gain.

information. Dietary restriction, particularly carbohydrate restriction, is frequently discussed within a paediatric population.

However, current evidence suggests long-term carbohydrate restriction is associated with lower fibre intakes, lower vitamin and mineral status, growth restriction and difficulties with adherence around food.11 2 Adequate and appropriate nutrition for growth Weight loss often precedes a diagnosis of T1DM.12 However, children living with T1DM are more likely to be overweight or obese than their peers,2 and childhood obesity remains a major public health concern. Dietetic support and messages from the team around building healthy relationships with food and body are key during childhood and adolescence, to prevent excessive weight gain and promote body positive messages. It is important to balance the message between ‘eating without restriction’ and health promotion messages to achieve appropriate weight gain.

3 Promote life-long healthy eating habits and relationships with food Establishing healthy and regularly managed meal routines, eating habits and positive relationships with food and body are particularly important for those living with T1DM. From mealtime battles during toddler years, to picky eating in childhood, and inappropriate dietary choices during teenage years, the role of the dietitian is crucially important. Concerns around body weight or shape can negatively impact selfesteem and body image.13 A diagnosis of diabetes can exacerbate lower levels of self-esteem14 and, therefore, contribute to difficult relationships with food and body and unhealthy dieting behaviours with inadequate or excessive weight change.

Clear, consistent nutrition messages delivered in a supportive and non-stigmatising way are crucial to fostering positive relationships with food.

4 Balance food and insulin to maximise glycaemic control Structured education to support carbohydrate counting and insulin dose adjustment should be

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COVER STORY Table 1: Summary of some of the diabetes technologies available Technology type

Example

Use

Benefit

Bolus advisors

Accu-Chek Bolus Advisor/Libre bolus advisors/app-based bolus advice (eg, mySugr/DiabetesM)

BG reading and bolus advisor

Meter advises insulin delivery based on insulin:carb ratio (ICR), insulin sensitivity factor (ISF) and BG, rather than user manually doing calculations.

Flash glucose monitor

Freestyle Libre + reader or smartphone app

Interstitial glucose reading when swiped by the user

Reduces need to finger prick test.

Gives reading and trend arrow.

Useful in exercise. Can be used to advise on bolus dose, when combined with a bolus advisor app.

Continuous glucose monitor (CGM)

Dexcom G6, Medtronic Guardian 3 sensor

Automated interstitial glucose reading every 5 minutes

Trend arrows predict direction of BG and rate of travel. Combined with Medtronic 640G can prevent hypo by switching off pump or 670G can semi automate basal rate.

Continuous subcutaneous insulin infusion (CSII) ( +/- augmented insulin pump)

Medtronic 640G+/Guardian 3 sensor, Omnipod+/-Dexcom G6

Insulin delivery fully instructed by user

No insulin pen injections.

24 adjustable basal rates.

Smaller bolus doses possible (down to 0.025u) vs pen (0.5u). HbA1c reduction: 0.5 %.

CSII hybrid closedloop (HCL) devices

Medtronic 670G or 780G + Guardian 3 sensor.

Tandem t:slim X2 +Dexcom G6

Insulin delivery partly instructed by user, semi-automated by algorithm

As per CSII, plus auto mode uses CGM readings to automatically correct high BG levels. User needs to wear CGM >70 % of time to get benefit. Improved HbA1c and increased time in range (TIR).

CSII hybrid closedloop (HCL) with dual hormones

In development: iLet Bionic pancreas

Insulin and glucagon partly instructed by user

Benefits of HCL devices with additional lowered risk of serious hypoglycaemic events and potentially removing the need for emergency intra-muscular glucagon injection.

DIY closed-loop system

Pump: Omnipod or Roche CGM: Dexcom G6 Device: AndroidAPS + Android Smartphone: OpenAPS + Small computer and Battery Loop + iPhone + RileyLink

Basal rate fully automated; user instructs pump when eating

Basal rates are automatically adjusted up to 200 times per day, depending on BG. Some systems remove the need to accurately carb count, as pump responds with microboluses following instruction of food being consumed.

User reported improved HbA1c, TIR, QoL and reduced burden.

offered to all CYP and their families.8 In addition, CYP should be offered tailored nutrition advice for sport and exercise, with the promotion of daily physical activity as well as individualised strategies for managing activity. Diabetes technology can play an important role in promoting self-management of this condition, and dietitians play a key role in supporting their use to aid education and inform insulin dose adjustments.

14

DIABETES TECHNOLOGY

The term ‘diabetes technology’ refers to devices and software that people living with T1DM use to help manage BG levels. This potentially reduces the risk of diabetes complications, the burden of living with T1DM and improves QoL.15 In a culture of patient-centred care, the improvement of QoL is of equal or greater importance to the CYP than physical health.

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COVER STORY

These systems link a smartphone, a compatible CSII device, a small computer and a CGM to automatically regulate changes in BG levels via micro-bolus’ of insulin every five minutes.

Currently, sensor augmented pumps (see Table 1) make up the majority of CSII device use in the UK. CSII and continuous glucose monitors (CGM) can assist with reducing episodes of hypoglycaemia, reducing HbA1c and improving time in range (TIR).16 CSII HCL devices such as the Medtronic 780G and the Tandem t:slim X2 are the most technologically advanced devices on the market today.

These HCL systems harness the data from CGM and use a regulatory algorithm to automatically adjust basal insulin and maximise TIR.17 Studies using HCL systems compared with CSII plus CGM alone, have demonstrated significant reductions in HbA1c and increased TIR.18-21 Patient-led, DIY (self-coded/programmed) closed-loop (fully-automated) systems such as OpenAPS (artificial pancreas system) or Loop, already exist, although these are not approved by regulatory bodies.22 These systems link a smartphone, a compatible CSII device, a small computer and a CGM to automatically regulate changes in BG levels via micro-bolus’ of insulin every five minutes.22 Patients report improved HbA1c, TIR and QoL. In response to the shift in medical management, Diabetes UK have produced a position statement23 to assist healthcare teams, with patients and families who choose to use this highly advanced yet non-certified technology.

However, the complexity and rapid change of diabetes technology can also be a barrier to the CYP and specialist MDTs facilitating and communicating diabetes care.15 Setting realistic expectations for the correct use of CSII and CGM is important, as is the identification and counselling of potential barriers to the adoption of new technologies.16

The general sentiment amongst diabetes professionals is that as technology progresses, a regulated and CE (European regulation) marked system, requiring no manual patient input, will exist and allow users to eat throughout the day without counting carbohydrates or entering in any BG levels.17 A system that requires minimal effort is the goal for the major diabetes technology companies, as it will significantly improve both QoL and health outcomes.

FUTURE OF NUTRITIONAL CARE IN PAEDIATRIC DIABETES

The landscape of paediatric diabetes care is rapidly changing, with emerging technologies, enhanced understanding of beta-cell function24 and the continuous availability of information and data. The role of the dietitian is ever recognised as essential for quality diabetes care, as demonstrated by the introduction of best practice tariffs in England, alongside a significant rise in dietetic care in Wales, Scotland and Northern Ireland. This has coincided with significant improvements to glycaemic control across the four nations.2 As dietitians and nutrition professionals, we are uniquely and highly skilled in providing comprehensive care support and advice to CYP living with T1DM, and our role as educators in this field should not be undersold. We have a capacity and capability to work as extended practitioners, with many colleagues achieving prescribing qualifications and/or working in advanced practitioner or diabetes educator roles. The unique skills of dietitians to understand the medical, nutritional, technological and psychological aspects of T1DM gives us the cutting edge when it comes to quality diabetes care and cost-effective service provision in the future.

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CONDITIONS & DISORDERS

HIV: THE ROLE OF NUTRITIONAL CARE IN SUPPORTING PATIENTS Human immunodeficiency virus (HIV) refers to two distinct viruses, HIV-1 and HIV-2.1 The most predominant virus, HIV-1, is responsible for 95% of all HIV infections. HIV continues to be a major public health issue and at the end of 2019, an estimated 38 million people were living with HIV worldwide.2

Gabriella Goodchild Registered Dietitian Freelance Gabriella started her career as a Community dietitian, working in care homes, nutrition support and weight management.

As a freelance dietitian, she now specialises in functional bowel disorders such as IBS, Intuitive Eating and has a particular interest in chronic illnesses.

REFERENCES Please visit: nhdmag.com/ references.html

16

In the UK, the most recent data suggests that there are around 103,800 people living with HIV and, of these, around 7500 are undiagnosed.3 This means that 1 in 14 people with the virus are not aware they have it.9 London continues to have the highest rates of HIV in the country. However, new diagnoses have been declining since 2005.3 HIV is most commonly passed on through sexual transmission and this accounted for 93% of people accessing HIV care in the UK in 2018.9 Sharing equipment for intravenous drugs accounts for only around 1.9% of transmissions in the UK.9 The virus can also be transmitted from mother to child during delivery or through breastfeeding, known as vertical transmission, but this accounts for only 2% of UK transmissions.9 The HIV virus attacks the immune system by destroying the CD4 white blood cells. A normal range for CD4 count is 500-1600 cells per cubic millimetre of blood (cells/mm3).7 Levels can fall below 200 cells in more advanced stages of the virus.

The reduction in CD4 cells caused by the HIV virus, means individuals gradually become immunodeficient and highly susceptible to infections and disease, which are often lifethreatening.2 Simultaneously, the HIV virus takes over by replicating and multiplying.2 The amount of HIV virus in the blood is referred to as the viral load.7 A viral load blood test looks for the number of HIV particles per millimetre of blood.7

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HIV SYMPTOMS

Symptoms of HIV vary depending on the stage of infection and how early an individual is diagnosed, but can initially often present as influenza-type symptoms, fever, rash, headaches and a sore throat.

As the infection progresses, symptoms can include swollen lymph nodes, weight loss, fever, diarrhoea and a persistent cough.2 Untreated, HIV will eventually develop into Acquired Immune Deficiency Syndrome, otherwise known as AIDS. AIDS, the late stage of HIV infection, is categorised by a very low CD4 count of less than 200 cells/mm3 and a severely compromised immune system.1 At this stage, the level of immunosuppression means a very high risk of diseases such as tuberculosis, pneumonia and some types of cancer.10 People with AIDS are very susceptible to illness and disease and typically survive around three years or less.

ANTIRETROVIRAL TREATMENT

Although there is no cure for HIV, antiretroviral drugs (ARVs) are, thankfully, very effective in reducing the level of HIV in the body, meaning more people with HIV live long and healthy lives and fewer people develop AIDS.1 If ARVs are taken as directed, the level of HIV in the body can be reduced to levels undetectable in the blood and the risk of transmission to others can be reduced.

Antiretroviral treatment (ART) is a combination therapy composed of two or more antiretroviral drugs (ARV).

These suppress viral replication and allow the immune system to recover.4

CONDITIONS & DISORDERS Figure 1: The mechanisms of different antiretroviral treatments

NUTRITIONAL INTERVENTION

Although a good balanced diet, staying active and good hygiene are consistent advice for those living with HIV, nutritional intervention will vary according to the stage of infection and health status of the individual. Dietary intake and meal pattern often need to be considered alongside ARV treatment. Whilst many ARVs are easily absorbed and can be taken with or without food, others have specific requirements to be taken with food or on an empty stomach.4 Intake may also be affected by side effects of the drugs. These can include nausea, diarrhoea and fatigue; however, these are less common with more modern ARVs and often improve

in the first few weeks.5 Some individuals may find their mood, appetite or sleep can also be affected.

A high-fat intake needs to be avoided for some ARVs, as this can lead to increased absorption and side effects.4 The drug Efavirenz was widely prescribed for more than 15 years and was known to cause significant side effects for some people, exacerbated by fat intake. However, since 2015, UK guidelines have recommended other drugs with lesser known side effects when starting ART.5 ARV SIDE EFFECTS

For ARVs that can be taken with or without food, taking with food may reduce side effects such as

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CONDITIONS & DISORDERS Figure 2: Mode of transmission of HIV

nausea.4 If nausea persists, medication may need changing or antiemetics may need prescribing.

Dietary advice to manage nausea may be helpful, including choosing bland, cold and dry foods whilst symptoms are present. Iced drinks, ginger or peppermint tea may help manage symptoms.

Meal pattern and methods of food preparation may also need to be considered whilst symptoms remain.

If an individual is experiencing diarrhoea, the potential cause of this needs to be considered. Diarrhoea can be a side effect of ARV medication. This can persist for weeks and sometimes months; for some this may become a more persistent symptom.11 Diarrhoea may be accompanied by poor appetite, abdominal pains and nausea.11 However, especially for those with a low CD4 count, other causes need to be considered, including a foodborne illness or gastrointestinal infection.11 Although dietary interventions in druginduced diarrhoea can be limited, dietary and lifestyle changes may be helpful to manage persistent diarrhoea.11 These include considering dietary fat and fibre intake, alongside any other potential dietary triggers such as caffeine or spicy foods. Adjusting fibre intake to increase soluble fibre sources and decrease insoluble sources may be useful to manage loose stools.

Individuals may also need to be advised around fluid intake and preventing dehydration.11 18

FOOD HYGIENE

Food safety and basic hygiene is a consideration for all those with HIV to minimise the risk of foodborne illnesses. This is especially important for those who are severely immunocompromised. Individuals should follow food safety advice around the storing, handling, eating and cooking of food.6 Those with a weakened immune system – often those with a CD4 count of less than 200 – should take additional care to avoid foodborne illness by avoiding higher risk foods such as pâté, raw or rare meat, raw or undercooked eggs and unpasteurised milk.6 RISK OF OTHER DISEASES

Metabolic changes are seen in some individuals with HIV.4 Changes in blood lipids, including raised cholesterol and triglyceride levels, can occur, caused by certain ARVs, increasing cardiovascular disease risk. Protease inhibitors, a type of ARV, increase blood lipid levels, which can contribute to hypertension.

People living with HIV may be more likely to have other risk factors for diabetes11 and links have been found between certain ARVs and Type 2 diabetes. Blood glucose levels may also need to be monitored more regularly. Also, people living with HIV have more incidences of bone mineral density loss and fragility fractures, perhaps caused by inflammation or side effects of ART.11

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CONDITIONS & DISORDERS Figure 3: How those living with HIV are encouraged to maintain their health

Nutritional and lifestyle intervention has an important place in helping those living with HIV reduce their risk of associated conditions.

In older drugs, changes in fat cells and the redistribution of body fat were common side effects; however, this is observed less with newer drugs.

In the UK, drugs linked with fat redistribution (lipodystrophy) are largely avoided,4 but patients who have gained weight or have reduced activity levels, may need extra support.

Individuals should be advised to avoid lifestyle choices that are likely to have a negative impact on their health and wellbeing, leading to increased risk, such as smoking, drug use or excessive alcohol intake. A high alcohol intake or substance misuse may also impact on adherence to HIV medication.7 The risk of liver damage from excessive alcohol intake is a concern, as the liver plays a vital role in processing ARVs.8 Individuals should be advised to drink within recommended guidelines and be directed to further support if needed.

COMPLEMENTARY REMEDIES

There is no clear evidence around the use of complementary therapies or herbal remedies.

Some herbal remedies may also interact with ARVs, including St John’s Wort, garlic capsules, echinacea, milk thistle, African potato and ginkgo biloba. Individuals with HIV should be assessed with regards to nutritional supplementation and this may be beneficial for some.

LATE DIAGNOSIS

Unfortunately, health status for some may be poor, often due to viral load, CD4 count, or other complications. Some people may find themselves with a late diagnosis. People who are diagnosed late, may have been living with HIV for around three to five years on average.9 Late diagnosis increases the risk of ill health, early death and onward transmission.9 Unfortunately, 43% of people newly diagnosed in 2018 were diagnosed at a late stage of HIV infection.9 Individuals with a poor health status or a late diagnosis may benefit from nutrition support, help to gain weight and improve nutritional status.

SUMMARY

Although prognosis is good with antiretroviral therapy, as individuals age, there may be further complications and increased health risks. Older adults living with HIV may need more support and intervention.

ARVs are very effective in reducing the level of HIV in the body, enabling more HIV patients to live long and healthy lives. Whilst nutritional intervention varies depending on the stage of infection and health status of the individual, nutritional and lifestyle interventions are important in helping those living with HIV reduce their risk of associated conditions.

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Introducing new ® Isosource Junior Mix Recipes Recipe cards are now available for individual feeds using Isosource® Junior Mix as a base. Working with our expert chef and in consultation with a Dietitian, the recipes support parents blending food: Supporting how-to videos online Nutritional information for each recipe Comprehensive support guides for Dietitians and parents or caregivers Tested to flow through Fr 14 tubes* Guidance on how to prepare blenderised feeds with Isosource® Junior Mix safely Please contact your Nestlé Health Science representative or visit our website for more information www.nestlehealthscience.co.uk/ isosource-junior-mix

Isosource® Junior Mix is a 1.2kcal/ml enteral tube feed for children aged 1 year and above that contains ingredients derived from food*

*Enteral UK recommends a minimum of 14Fr feeding tubes with the Isosource® Junior Mix recipes. Enteral UK and Nestlé Health Science worked in collaboration to test the viscosity of each feed. ᵻ Isosource® Junior Mix contains 13.8% food derived ingredients (rehydrated chicken meat & rehydrated vegetables, peach puree, orange juice from concentrate).

For Healthcare Professional Use Only. ®Reg. Trademark of Société des Produits Nestlé S.A. 10/2020.

Isosource® Junior Mix is a food for special medical purposes for use under medical supervision.

GUM-BASED THICKENERS: HOW TO GET THE BEST OUT OF THEM

NUTRITION SUPPORT

This article looks at the properties of gum-based thickeners and how best to use them within the IDDSI Framework for food textures and drink thickness.

Thickeners are an important tool in the box for reducing the risk of gagging, choking and aspiration in patients with dysphagia.1 They’ve been around for a long time, with a range of starch and gum-based products being available on the market now. Over the last decade, healthcare professionals have moved towards gum-based thickeners, as they generally provide a smoother texture, more appealing mouthfeel and a stable consistency even after the fluid has been sitting for some time.

Gum-based thickeners consist of xanthan gum and a few other ingredients, such as maltodextrin and erythritol.

Each product has its own unique blend of these common ingredients, meaning they’ll all perform slightly differently when used to thicken different fluids to different International Dysphagia Diet Standardisation Initiative (IDDSI) levels.8 They’re generally gluten and milk free.

One of the major benefits of using a gum-based thickener over a starchbased version is that it tends to produce a smoother mouthfeel and texture.

Compared side by side, you may notice that fluids thickened with a starch-based thickener may have a grainy mouthfeel

to them. Gum-based thickened liquids, however, feel slicker and smoother. This is due to gums creating a mesh-like structure in the mixture, meaning the water molecules become lodged in place, with less opportunity for clumping.9 As more gum-based thickener is added to the liquid, more mesh-like structures are created, tangling more of the water molecules. This results in a thicker final mixture. Gum-based thickeners tend to remain stable once thickened to the desired IDDSI level.

Starches, on the other hand, swell when mixed with liquid.9 This reaction isn’t always uniform and can result in a lumpy final mixture. Starch-based thickeners also continue to thicken over time, leading to an over-thickened product by the time the patient is ready to consume the fluid or finish a drink they may have started to consume a while ago.

Emma Coates Registered Dietitian Emma has been a Registered Dietitian for 14 years, with experience of adult and paediatric dietetics. coatesyRD

REFERENCES Please visit: nhdmag.com/ references.html

USING GUM-BASED THICKENERS IN FLUIDS

When using gum-based thickeners in fluids, it’s important to remember that each product is made up of a different blend of ingredients. They will all have their own unique properties and performance.

IDDSI The IDDSI Framework was adopted and introduced into the UK in April 2018. It has now fully replaced the old national descriptors that were in place until that time. The Framework consists of ‘a continuum of 8 levels (0-7), where drinks are measured from Levels 0-4, while foods are measured from Levels 3-7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness.’ 8 A full overview of the Framework plus useful resources can be found via the IDDSI website: www.iddsi.org IDDSI also produce regular updates via their social media pages, webinars and e-bite monthly newsletters, which you can subscribe to via their website. www.NHDmag.com December 2020 / January 2021 - Issue 159

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NUTRITION SUPPORT Table 1: Gum-based thickeners available on prescription in the UK - common ingredients and properties Ingredient

E number

Properties

Product

Xanthan gum

E415

• Natural polysaccharide • Produced by the bacterium Xanthomonas campestris from sugar and molasses • Thickening agent • Stabiliser • Emulsifier

• Thick & Easy Clear (Fresenius Kabi)2 • Nutilis Clear (Nutricia)3 • Resource ThickenUp Clear (Nestle Health Science)4 • Swalloweze Clear (Nualtra)5

Guar gum6

E412

• Natural polysaccharide • Produced from the guar shrub (Cyamopsis tetragonolobus) • Thickening agent • Stabiliser • Emulsifier

• Nutilis Clear (Nutricia)

Maltodextrin6

N/A

• Carbohydrate • A degradation product of starch • Consists of short chains of glucose molecules • Often used as a filling agent

• Thick & Easy Clear (Fresenius Kabi) • Nutilis Clear (Nutricia) • Resource ThickenUp Clear (Nestle Health Science) • Swalloweze Clear (Nualtra)

Carrageenan6

E407a

• Natural polysaccharide • Produced by different seaweeds (Chrondrus crispus, Gigartina stellata, Euchema spinosum, E. cottonii) • A complex mixture of polysaccharides • Contains cellulose • Thickening agent • Stabiliser • Emulsifier

• Thick & Easy Clear (Fresenius Kabi)

Erythritol7

E968

• A sugar alcohol or hydrogenated carbohydrate • Produced by fermentation using yeast • A sugar replacer – bulk sweetener or sugar-free sweetener

• Thick & Easy Clear (Fresenius Kabi) • Resource ThickenUp Clear (Nestle Health Science) • Swalloweze Clear (Nualtra)

Potassium chloride

E508

• Natural salt – from sea salt and rock salt • Salt replacer • Found in many salt-free/sodiumfree/low-sodium products

• Resource ThickenUp Clear (Nestle Health Science)

6

There are a number of things that can affect the performance of the thickener, some of which are within the control of the manufacturer or the product user; however, some are beyond our control. Table 3 on page 23 contains some examples of common issues when using gumbased thickeners and how to troubleshoot them.

As with many commercial powdered products (for example, gravy or custard), there is always the potential for the end result to be nothing like what it says on the tin. However, 22

practice can make perfect. Over the years, I have experimented with thickeners in both my clinical and industry roles and the results of my tinkering with them hasn’t always resulted in nice, smooth, enjoyable drinks!

Follow the instructions Getting to know a product by practicing with it is key to successful and reproducible results. Each product on the market has its own scoop size and mixing instructions. It’s important to follow

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NUTRITION SUPPORT Table 2: Types of syringes IDDSI flow testing types of syringes BD 302188 syringes were previously available in Europe until 2018. They are no longer available.

Available in Europe

Coming soon!

BD 305959 syringes have a Luer-lok screw thread around the outside of the nozzle. They have the same internal nozzle dimensions as the US syringe 303134, therefore will give the same results.

The IDDSI funnel has been designed with the same dimensions as the BD 303134 and BD 305959 syringes.

—

—

BD 303134 syringes are a US syringe which are suitable for IDDSI flow testing.

IDDSI has recommended that European IDDSI users ensure that 10ml BD 305959 syringes are used for flow testing – see highlighted in the red box in the image on page 24.

Table 3: Common issues when using gum-based thickeners to thicken fluids to IDDSI levels 1-4 Issue

Troubleshooting

Action

My drink hasn’t thickened like it says on the tin.

Have you followed the manufacturer’s instructions correctly?

You may have to repeat the mixing stage if you haven’t followed the instructions as per the tin.

Have you conducted an accurate IDDSI flow test?

Conducting an accurate IDDSI flow test is paramount to obtaining a safe usable result for your patient.

Have you left it to stand long enough before flow testing?

Thickening fluids such as milk, fresh juices and hot drinks usually takes longer than water because of their fat/sugar/electrolyte content or pH level.

Incorrect mixing processes at this stage can affect how well the product mixes with the fluid, resulting in poor thickening/clumping of the product.

Often require anything between 3-10 minutes to reach the desired IDDSI level depending on the level, type of fluid, fluid temperature and thickener product used.

Are you trying to thicken oral nutritional supplements (ONS)?

ONS are challenging to thicken and will require different amounts of thickener to thicken different ONS products to IDDSI levels 1-4.

Manufacturers may advise that some ONS products shouldn’t be thickened because they don’t thicken well or at all, or they’re not palatable or appealing to patients when thickened.

Contact your thickener manufacturer for advice if you are recommending thickening ONS for your patient.

I’ve IDDSI flow tested my thickened drink and it’s exactly 4ml or 8ml.

What level is it?

The sample is neither a level 2 nor level 3.11 A sample that tests at exactly the IDDSI cut-off point of 4ml to 8ml is between levels.11

Your mixture needs to be adjusted to meet the desired level11 – if you’re sure that you’ve followed the manufacturer’s instructions, you’ve let it stand for long enough and you’ve completed an accurate flow test (see above).

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23

NUTRITION SUPPORT

Use the correct syringe

Ensuring you use the correct syringe type is also vital to produce reliable results . . . . . . IDDSI have given a recent update to their guidance on syringe types, which are suitable for flow testing.

these and repeat them to ensure you get used to how the product performs. One key thing to remember here is: don’t expect all products to react in the same way in different liquid types (fat, electrolyte, sugar and pH levels all play a part here), at different fluid temperatures and when thickening to different IDDSI levels.

Know the IDDSI Framework It’s also paramount that you are familiar and comfortable with the IDDSI Framework and flow testing your fluids. Conducting an accurate flow test can take a few attempts to perfect and is something that should be completed rather than ‘eyeballing’ a mixture and thinking, “that looks like a level 2 to me”.

Use the correct syringe Ensuring you use the correct syringe type is also vital to produce reliable results. A 10ml ‘slip tip’ syringe should be used to complete the flow test (also known as a ‘Luer-slip tip’ syringe). IDDSI have given a recent update to their guidance on syringe types, which are suitable for flow testing.

In their January 2020 e-bite,10 they informed us of disruption to the supply of some suitable syringes and gave alternative suitable options available in Europe. This included an update on 24

the development of the IDDSI funnel, which has the correct 10ml dimensions for flow testing and also includes easy-to-follow IDDSI levels on the side. See Table 2.

TROUBLESHOOTING

Thickeners are a vital tool in the safe management of dysphagia; however, they take some skill and practice to get to grips with. Effective use of a thickener takes a little time investment from the product user to perfect. This should be taken into account when thickening fluids for patients and training patients/carers to use them effectively and safely. Incorrect or poorly mixed thickened drinks are a hazard to patients and can significantly reduce enjoyment of fluids for patients who may already have limited fluid intakes due to their swallowing problems. See Table 3 for how to resolve common issues.

SUMMARY

Getting to know a thickening product well, in addition to being competent in the use of the IDDSI Framework and flow testing, is paramount to safe and successful use of thickeners. It will mean that patients will be provided with enjoyable, palatable fluids at whatever IDDSI level they require.

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HYPOTHYROIDISM: LINKS BETWEEN HASHIMOTO’S THYROIDITIS AND NUTRITIONAL STATUS The influence that hypothyroidism can have on weight has become general knowledge. However, there is so much more to it than just a number on the scales. Researchers are unceasingly investigating single nutrients and their influence on dysfunctional thyroid glands. This article outlines nutritional implications in the most common cause of primary hypothyroidism in iodine-replete populations – Hashimoto’s thyroiditis.

Hashimoto’s thyroiditis (HT), also known as Hashimoto’s disease or chronic lymphocytic thyroiditis, was first acknowledged in 1912 by Japanese physician Hakaru Hashimoto. He established that a thyroid being infiltrated by lymphocytes produces anti-thyroid antibodies, which attack thyroid tissue, leading to progressive fibrosis.1,2 Historically, the diagnosis was based on observations during or after thyroidectomy, limiting the number of patients who could be diagnosed. It wasn’t until the rise in use of biopsy, ultrasound and antibody tests that HT became the

most commonly diagnosed thyroid dysfunction. The clinical presentation of HT is highly variable. It can cause hypothyroid symptoms as well as those similar to hyperthyroidism. Currently, the diagnosis is primarily based on the biochemical picture. Elevated serum thyroid-stimulating hormone (TSH), with low free thyroxine (FT4), imply primary hypothyroidism. The additional presence of anti-thyroid peroxidase (TPOAb) and anti-thyroglobulin (TgAb), indicates HT, although up to 10% of patients may have negative antibodies.2,3,5,8 Interpretation of thyroid function testing has been presented in Figure 1.

CONDITIONS & DISORDERS

Bogna Nicińska RD Specialist Diabetes Dietitian 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: nhdmag.com/ references.html

Figure 1: Algorithm for the interpretation of thyroid function test results2

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CONDITIONS & DISORDERS

Iodine deficiency is the most common cause of hypothyroidism globally and affects over a billion people.

TREATMENT AND INTERACTIONS

Thyroid hormones affect every organ in the body. They regulate energy metabolism, affect muscle development and neuronal growth, and influence glucose, protein and lipid metabolism.

Depending on the metabolic state, thyroid hormones can be responsible for anabolic or catabolic processes of lipids, glucose and proteins.3-5 Untreated hypothyroidism can have profound adverse effects, eventually leading to coma or even death. With treatment, i.e. thyroid hormone replacement, the symptoms usually reverse in a few weeks or months. The drug of choice is titrated levothyroxine sodium (LT4). Its absorption occurs in all parts of the small intestine and ranges between 62% to 84% of the ingested dose. To optimise the process, LT4 should be taken on an empty stomach.

Foods, such as grapefruit, wheat bran, soya and caffeine, decrease its absorption, so should be avoided. Dietary supplements rich in fibres, calcium supplements and some medications also cause suboptimal absorption, including: • sucralfate (treats duodenal ulcer disease, gastritis); • cholestyramine (lowers LDL-cholesterol); • over-the-counter medicines containing aluminium hydroxide (relieve acid indigestion); • proton pump inhibitors (prevent and treat stomach and duodenum ulcers).

These supplements and medications, therefore, should ideally be taken four to six hours after LT4 administration.3,4,6,9 The hypothyroidism aetiology combines genetic (not yet well understood), dietary (nutritional status of selenium, iodine, iron and vitamin D), environmental and demographic 26

(infection, iodine and selenium intake, certain drugs and chemicals) risk factors.1,2,4,6 IODINE

Iodine deficiency is the most common cause of hypothyroidism globally and affects over a billion people (see Figure 2). Many countries have introduced mandatory salt iodisation to try to combat this issue (see Figure 3).

Iodine is a crucial constituent of the thyroid hormones, thyroxine (T4, prohormone) and triiodothyronine (T3, active hormone). In the absence of iodised products, a diet rich in fish of the right species and provenance, seafood and dairy (given cows are supplemented and/ or iodophor sanitising agents are used to clean the cows and milk-processing equipment) might increase iodine levels.2,4,7,8 In iodine-replete populations, the leading cause of hypothyroidism is HT. Excessive intake, or prolonged iodine exposure, even in an initially deficient patient, can cause thyroid autoimmunity, although the mechanism is not fully understood. It is believed that excess iodine causes thyroglobulin to be more immunogenic and, in consequence, leads to autoimmune disease. Nuclear incidents have significantly increased rates of thyroid diseases in the areas surrounding Chernobyl, Hiroshima, Nagasaki and Marshall Island (USA atomic tests). For instance, due to the release of radioactive iodine following the Chernobyl accident, in Eastern Europe the prevalence of thyroid disease increased to 62 times the regular rate. 1,2,7-9 SELENIUM

In the human body, selenium is found in the thyroid gland in immense abundance. Seleniumcontaining proteins (selenoprotein) are involved in the activation of thyroid hormones

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CONDITIONS & DISORDERS Figure 2: Global iodine status 202010

Insufficient iodine intake

Optimal iodine intake

Excess iodine intake

Figure 3: Mandatory iodisation11

No mandatory iodisation and inflammatory response. Evidence from randomised controlled trials and observational studies indicates selenoprotein can reduce levels of thyroid antibodies as associated with the pathogenesis of thyroiditis. As in the case of iodine, selenium intake differs vastly from one part of the world to another, owing to

Mandatory iodisation

differences in the selenium content of the soil in which crops are grown and how livestock are fed (see Figure 4 overleaf). The richest dietary source of selenium are Brazil nuts. However, it is worth noting they can be high in barium and that selenium content can vary greatly between 0.03 to 512 mg/kg of fresh weight.1,4,12-14

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CONDITIONS & DISORDERS Figure 4: Typical selenium content of food sources adapted from WHO1,15

0 0.25 0.50 0.75 1.00 1.25 1.50 Typical selenium content of foods (mg/kg)

The most recent (2016) meta-analysis of 16 trials found that 200mcg of l-selenomethionine supplementation orally in deficient patients for six months, reduced serum anti-thyroid antibody levels after three, six and 12 months in a population with chronic autoimmune thyroiditis treated with LT4. Analogously to iodine, excessive selenium intake causes adverse health effects.12,13,16 IRON

Patients with HT frequently are iron-deficient compared with the healthy population. Often it is due to the presence of common comorbidities like autoimmune gastritis or coeliac disease.3,4 Studies suggest that in patients with serum ferritin below 70Âľg/l, coeliac disease or autoimmune gastritis should be investigated. Iron deficiency impairs thyroid hormone production decreasing the activity of thyroid peroxidase (TPO), the enzyme responsible for the production of thyroid hormones.3,4,6-8,17 Studies suggest that iron anaemia can be 30-50% responsible for persistent symptoms of hypothyroidism despite adequate levothyroxine treatment. Supplementation of 300mg of ferrous sulphate daily for 12 weeks in anaemic women with impaired thyroid function led to an elevation in serum TSH. Iron supplements, together with LT4 administration, are more effective in improving iron status.18,19 OTHER NUTRIENTS

Researchers have been investigating additional potential associations between diet and HT; however, there is not yet enough evidence to make official recommendations. For instance, there is insufficient data available on the 28

relationship between vitamin A, zinc and their connection to HT, despite these nutrients being involved in thyroid metabolism.3,7 A systematic review, meta-analysis and metaregression of observational studies indicated that patients with HT have lower mean serum 25(OH)D than controls. However, it is uncertain if low vitamin D status is a result of the vitamin D receptor dysfunction or the autoimmune disease process.3,6,20 A 2018 systematic review and meta-analysis of 15 studies enrolling 44,140 individuals, showed hypothyroidism is significantly associated with the presence and severity of non-alcoholic fatty liver disease (NAFLD). The authors of the review believe this association is because of hepatic de novo lipogenesis stimulated by elevated serum TSH. The authors suggest the introduction of screening of hypothyroid patients for NAFLD and, conversely, NAFLD patients for hypothyroidism.21 There is also a theory suggesting that leaky gut syndrome plays a role in HT pathogenesis, in which case, implementation of an antiinflammatory diet could be of benefit. However, the evidence is scarce, and more research is required before setting recommendations.2,4,7 CONCLUSION

In light of emerging studies, it is worth keeping in mind the above-mentioned nutrients and their potential relationship with HT. In future, it may become important to screen patients with hypothyroidism for NAFLD or nutrient deficiencies, including iron, vitamin D, or selenium, where clinically indicated, to ensure that patients are receiving appropriate treatments to minimise their symptoms.

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COMMUNITY

DIETARY ADVICE IN MENOPAUSE Oestrogen deficiency in menopause causes lipid metabolism and bone changes that can be counteracted to some extent by energybalanced dietary interventions. This article considers how nutrition can relieve symptoms during the menopausal transition.

Menopause is the end of a woman’s reproductive period and, in most women, occurs between the ages of 40 and 60 years.1 This coincides with many unpleasant symptoms such as hot flushes, night sweats, insomnia, anxiety and depression.2 These symptoms usually begin two years before the menstrual cycle ends and continue for up to four years.

Menopause is now less of a taboo topic in the media due to grassroots projects such as the Menopause Cafe, this year’s release of the book Menopocalypse by Amanda Thebe, and the Menopause Festival (aka #Flushfest) becoming popular.3,4 As awareness and social acceptance of peri- and postmenopausal symptoms increase, it is believed that the associated increased burden of disease will rise too.5 PATHOPHYSIOLOGY: MECHANISM OF OBESITY IN MENOPAUSE

During the menopausal transition, androgen levels increase whilst oestrogen levels decrease. This hormonal imbalance regulates hunger and satiety signals, altering energy homeostasis.6 A progressive reduction of physical activity is also observed with ageing, possibly due to diminished muscle strength limiting functional ability to perform daily activities.7 When these factors of menopause are combined, they result in body composition changes, mainly an increase in weight and total fat, a decrease in fat-free mass and an increase in visceral adiposity8 (see Figure 1).

In several observational studies, more frequent or severe menopausal symptoms have been reported in women with a larger body mass index (BMI), or greater body fat percentage

when compared with women of a lower BMI.9,10 Approximately 40% of women in the menopausal transition are overweight or obese, and the remaining 60% are at risk of weight gain secondary to loss of muscle mass and a decrease in basal metabolic rate.11,12 Higher BMI is an independent risk factor for uterine, endometrium and breast cancers. In addition to this, the continuous production of oestrogen by adipose tissues during menopause is responsible for a high cancer risk in premenopausal women.13 Consequently, managing weight in pre- and perimenopause is of high priority. Many women consider hormone replacement therapy (HRT) for weight management; however, there is contradicting literature on whether it supports or refutes weight loss efforts, and its role in metabolic risk prevention requires more research.14 Moreover, whilst HRT is an acceptable treatment for these symptoms, the limitations arising from associated health risks make modifying lifestyle factors more important.

There are no specific dietary guidelines for weight management in menopause. Instead, the aim of dietary intervention is to offset weight gain and thus prevent the metabolic disorders typical of menopause, such as Type 2 diabetes and cardiovascular disease. A high adherence to the Mediterranean diet has been shown to be associated with a cardioprotective effect in peri- and menopausal women, such as significantly reducing cholesterol, resting heart rate and triglycerides.14 However, the studies available currently are cross-sectional, with a small sample size, limiting the ability to extrapolate them to the wider

Harriet Drennan Diabetes and Acute Medicine Dietitian Harriet is a Specialist Diabetes and Acute Medicine Dietitian at the University Hospital of North Midlands.

REFERENCES Please visit: nhdmag.com/ references.html

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COMMUNITY Figure 1: Body composition changes Menopausal Transition

Decline in BMR Decline in Physical Activity

Follicular Depletion Oestrogen Deficiency

Hormonal Fluctuation

Oestrogen Deficiency

Androgen Excess

Altered Energy Homeostasis

Body Composition Changes Increase in Weight and Total Fat Increase in Visceral Adiposity Decrease in Lean Mass

population. A recent cross-sectional study found that increases in total fruit and vegetable intake could potentially be linked with menopausal symptoms, supporting the suggestion that a Mediterranean diet can provide beneficial effects for menopausal women.15 However, the subtypes of the effective fruit and vegetables are yet to be identified. Validity of this study was increased, as participants receiving HRT in the past six months were excluded.15 When seeing women of pre- or perimenopausal age for weight-loss intervention, it is important to remember that they are likely to encounter more barriers during weight loss attempts than the general adult population, such as more intense hunger signals. As the menopausal stage favours adiposity, failure to lose and maintain weight could enhance psychological distress, a potential cue for unhealthy eating behaviour.8 CALCIUM AND VITAMIN D

There are indications that metabolic syndrome (MetS) is more prevalent in postmenopausal women who have insufficient or deficient levels of vitamin D compared with those with 30

normal vitamin D levels.16 MetS is defined as the presence of at least three of the following: serum triglycerides >1.7mmol/l, high-density lipoprotein cholesterol <1.3mmol/l, fasting plasma glucose of >5.5mmol/l, blood pressure >130/85â&#x20AC;&#x2030;mmHg and waist circumferenceâ&#x20AC;&#x2030;>88cm.17 As transition to menopause increases the risk of cardiovascular disease due to a composite of risk factors (eg, due to insulin resistance and abdominal obesity), it is important that MetS is prevented in order to hinder further detrimental health outcomes.18 A cross-sectional study examining 616 postmenopausal women, found that a higher vitamin D content in the participantsâ&#x20AC;&#x2122; blood profiles was significantly associated with favourable lipid profiles, blood pressure and glucose levels.19 This is supported by a recent double-blind RCT which found a supplementation of 1000IU vitamin D3/day was associated with a significant reduction in serum triglycerides, insulin, and also homeostatic model assessment of insulin resistance values.20 There was also a lower risk of presenting with MetS and hyperglycaemia in those who took vitamin D3 when compared with the placebo

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COMMUNITY group, after adjustments for age, time since menopause, physical activity and BMI.19 This evidence suggests that the risk of MetS may be reduced by a diet rich in vitamin D and an optimal vitamin D supplement.

Ideally, all peri- and postmenopausal women should be screened for vitamin D deficiency, as osteoporosis is most common after the menopause.8,17 A recent Consensus Statement on vitamin D states that vitamin D supplementation combined with adequate calcium intake can reduce the incidence of fractures in elderly vitamin D deficient subjects.20 Despite this, evidence for treatment with vitamin D and calcium alone for the prevention of fractures in the postmenopausal population is limited.21 However, a 2020 retrospective study found that serum levels of 25(OH)D (a pre-hormone produced in the liver by oxidation of vitamin D3) was an independent risk factor for fragile hip fracture, with the condition that femoral neck bone density had reached the threshold of osteoporosis.22 This was conducted in women of peri- and postmenopausal age (50 to 98 years).22 This warrants suggesting a vitamin D supplement to reduce the risk of fragile femoral neck in this subject group.

PLANT OESTROGENS

As oestrogen levels decline during menopause, it is suggested that eating phytoestrogens can mimic the effects of human oestrogen and subsequently reduce menopausal symptoms.

This mimicking is termed ‘endocrine disruption’.24 The BDA recommends plant oestrogens, or phytoestrogens, found in soy.23 As worldwide consumption of soy is increasing due to the popular rise of vegetarianism and veganism, more consideration of its endocrinedisrupting properties is required.

A recent cross-sectional study showed a significant reduction in menopausal symptoms when soy milk consumption was significantly greater compared with the control group, who increased skimmed dairy products.25 The efficiency of phytoestrogens (eg, soy isoflavones, red clover) to reduce menopausal symptoms remains unproven due to inconsistent results.

Trials have been limited by small sample sizes and lack of long-term follow-up. Despite this, phytoestrogens continue to be one of the most

popular non-pharmacological therapies for menopausal symptom control.26 If patients wish to try phytoestrogens, they should be encouraged to avoid oral supplements and instead trial adding foods rich in phytoestrogens to their diets for two to three months. Foods include linseeds and linseed bread and soya products such as yoghurts, milk and edamame beans. It is believed that it may take up to two to three months for the benefits of phytoestrogen consumption to be felt or observed.24 As it’s thought that one larger dose is less effective than many smaller ones, practical suggestions for adding these foods into a patient’s daily diet should be provided.

ANTIOXIDANTS

A certain degree of antioxidant protection against oxidative stress is lost in the menopause due to significant oestrogen decline.27 Menopausal women are consequently more exposed to free radicals.28 Many observational studies have shown that a higher antioxidant content has been related to alleviation of physical and psychological menopause-associated symptoms, fewer vasomotor symptoms and better psychological wellbeing in menopausal women.28 Unfortunately, research in this area is limited and more evidence is required to identify particular antioxidative foods that protect the cellular components from oxidative stress caused due to oestrogen deficiency.

However, the available evidence supports the promotion of a Mediterranean-style diet which contains antioxidant rich vegetables.29 CONCLUSION

As oestrogen deficiency causes alterations in lipid metabolism and bone turnover, consideration of dietary intake is warranted to help counteract these changes. These will, of course, need to be adjunct to energy-balanced dietary interventions.

KEY POINTS: • Maintain a healthy BMI. • Ensure a 10mcg vitamin D supplement and sufficient calcium intake.

• Consider the patient’s phytoestrogen intake.

• Encourage balanced meals consisting of plenty of fruit and vegetables.

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PUBLIC HEALTH

BONE HEALTH THROUGH THE LIFESPAN Bone health is important at all ages. Here, we look at the importance of bone health throughout life and discuss how healthcare professionals (HCPs) can make a positive impact by optimising dietary management.

During infancy and childhood, bone health is important to aid mobility and normal development.1 Children rely on their skeleton to move and interact with the world. Calcium requirements need to be met to facilitate this, which can be difficult for some families to achieve.

Dairy foods are the main source of calcium during growth and, therefore, it is important that children who avoid dairy get their calcium via other means.2,3 Good bone health at this age also maximises bone mass later in life and can delay the onset of age-related osteoporosis.1 After puberty, bone continues to consolidate, although more slowly.4 Peak bone mass (PBM), which is defined as the amount of bone present at the end of skeletal maturation, is a major predictor of fracture risk in later life.5 The attainment of PBM is thought to be achieved by 30 years of age in both men and women, but it can be as early as late teenage years or late as mid 30s depending on the skeletal site.6 This emphasises the importance of bone health during this â&#x20AC;&#x2DC;window of opportunityâ&#x20AC;&#x2122;, after which it becomes increasingly difficult to build upon.

PRE- AND POSTNATAL PERIOD

In pregnancy, there are two skeletons to consider: that of the mother and the child. Bone health for both is a priority during this time. Calcium is vital for developing the foetal skeleton and

Naomi Oxberry Registered Dietitian

maintaining maternal bone health.7 Meeting calcium requirements is important for all mothers, but it may be especially important in adolescent pregnancy, as the mother may still be building her own bone density.8 For mothers who are breastfeeding, calcium requirements increase significantly. This can be difficult to achieve and, therefore, it is important to help mothers meet these targets, ideally with diet.7

Naomi graduated from the University of Nottingham as a Registered Dietitian and currently works across the National Health Service and the private sector.

She has a Masters from The London School of Hygiene and Tropical Medicine.

THE OLDER POPULATION

The United Nations predicts that the global number of persons over the age of 65 is estimated to double to 1.5 billion by 2050.9 Osteoporosis and other musculoskeletal disorders are the most common problems affecting the elderly,10 therefore bone health is a key concern for this population demographic. Keeping bone health optimal throughout the lifespan helps to maintain good bone density and reduce fracture risk whilst ageing.11 However, there is now strong evidence to suggest that bone health can still be improved in the latter years. A recent study showed that food-based interventions improved mobility for older people. Within a cohort of 813 care residents, there was a 42% (P<0.001 95% CI 0.44-0.78) reduction in the number of institutionalised elderly falls after 12 months of supplementation of protein, calcium and vitamin D12.

REFERENCES Please visit: nhdmag.com/ references.html

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PUBLIC HEALTH

At whatever stage of life, exercise is an important part of our lifestyles to maintain general health and wellbeing.

Exercise is one of the primary modifiable factors associated with improved bone health outcomes.

EXERCISE

At whatever stage of life, exercise is an important part of our lifestyles to maintain general health and wellbeing. Exercise is one of the primary modifiable factors associated with improved bone health outcomes.13 For children, exercise is pivotal. This is because osteogenesis is more pronounced during the peripubertal stage. Longitudinal studies show that individuals who were active during childhood had an 8-10% greater hip bone mineral content in adulthood than their sedentary counterparts.14 In fact, a 6.4% decrease in bone mass in childhood has been associated with a twofold increase of fracture risk during adulthood.15 In adulthood, exercise can further consolidate good bone health. Premenopausal women aged 35 to 45 years who performed a high impact exercise regime had progressive increases in bone mineral density at the femoral neck.16 Walking and other low-to-moderate impact exercises improved bone health, but resistance, strength, aerobic and whole body vibration exercises were more effective.17 For 34

postmenopausal women, there is a certain level of â&#x20AC;&#x2DC;anabolic resistanceâ&#x20AC;&#x2122; to exercise due to reduction in oestrogen levels. However, exercise has recently been shown to produce localised cortical and trabecular bone changes that affect bone strength independently to bone mass, showing that exercise can strengthen bones even with a lack of oestrogen.18 Older adults who continue to be active can also improve their bone health. This was seen in a recent meta-analysis of randomised controlled trials, which showed an improvement in bone mineral density in the lumbar spine and femoral neck in those who exercised, illustrating the importance of exercise despite age.19 DIETARY DISEASE ASSOCIATED WITH BONES

Rickets and osteomalacia Small bone cells, called osteoblasts secrete osteoids. These are gelatinous and are made up of collagen and fibrous proteins. Osteoids are the soft framework of bone before calcium phosphate is deposited onto them, which then forms mineralised bone. In rickets and osteomalacia, osteoids fail to calcify.20 There

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PUBLIC HEALTH has been an increase in cases of rickets in the UK.21 Osteomalacia is very similar to rickets but presents in adults. Vitamin D is needed to absorb calcium and phosphorus from food. Both rickets and osteomalacia can be caused by a lack of vitamin D and can also be from a lack of calcium.20 The Department of Health and Social Care recommends that: • breastfed babies from birth to one year of age should be given a daily supplement containing 8.5 to 10 micrograms of vitamin D; • formula-fed babies shouldn’t be given vitamin D until they are having less than 500ml; • children aged 1-4 should be given a daily supplement containing 10 micrograms of vitamin D; • over four years of age, everyone should take 10 micrograms of vitamin D daily, especially during the autumn and winter months.22 Scurvy Bone is mostly made of collagen, which has a triple helix conformation. In order to keep this triple helix together, vitamin C is needed.

Without vitamin C, the helix degrades and collagen loses its functionality. This will lead to harmful effects in collagen-containing tissues, for example, in the mouth and in the bone.23 Ehlers-Danlos (ED) syndromes ED syndromes are a group of conditions that cause flexible joints or hypermobility. ED is characterised by abnormal connective tissue, though some papers have also found bone involvement. This includes a reduced bone mineral density and possibly an increased fracture risk.24 For dietitians, nutritionists and healthcare providers, it is important to acknowledge its strong link with irritable bowel syndrome.25

CALCIUM SUPPLEMENTATION

There are choices when it comes to calcium supplementation. Calcium carbonate tends to be the best value because it contains the highest amount of elemental calcium by weight.26 However, there are three main downsides.

Firstly, because calcium carbonate requires stomach acid for absorption, it’s best to take this product with food. The supplement may then compete with minerals, such as iron, within the diet. Secondly, only around 500mg of calcium can be absorbed at a time; therefore, supplements may compete with calcium from the diet. Thirdly, it can cause gastrointestinal upset, especially constipation.27,28 Calcium citrate supplements do not rely on stomach acid; therefore, they do not need to be taken with food. This also means they are potentially better for patients on proton pump inhibitors. These supplements are absorbed more easily than calcium carbonate and cause less GI upset. However, calcium citrate has less calcium by weight and may require taking more than one tablet a day, depending on the brand chosen.28 Please note that: • both calcium carbonate and calcium citrate products can be found with vitamin D; • there are other types of calcium supplementation; • those who start antibiotics or levothyroxine would be advised to tell their doctor when also taking calcium supplementation.

CONCLUSION

Bone health impacts on overall health throughout life. How healthy our bones are now can affect our health in the future. Healthcare professionals have a big role to play in optimising bone health across a patient’s lifespan; with small changes they can facilitate significant results.

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THE IMPORTANCE OF MULTIDISCIPLINARY TEAM WORKING

SKILLS & LEARNING

In this article, Claire Irlam RD, reflects on moving from a dietetic team into a multidisciplinary service.

I am sure that the beginning of April 2020 will come to be a time we will all remember – the start of lockdown and only being able to leave home for one daily exercise, essential work and buying necessary groceries. But for me, it also signalled the start of an exciting new role, which was to be quite different from any I had undertaken in the past.

I was to be based within Manchester’s community Macmillan team, which provides a supportive and palliative care service (after saying I would never do community work). My former roles had certainly always involved elements of multidisciplinary team (MDT) working whilst visiting different wards, but I had always been based within a dietetic department. I would start each day by triaging new dietetic referrals, returning to the office for lunch and debriefing at the end of the day – all whilst being surrounded by fellow dietitians.

The team I now sit within aims to provide a supportive service to the people of Manchester who are living with life-limiting conditions, with a life expectancy of approximately 12 months or less.

We provide access to specialists in palliative care including medics, nurses, assistant practitioners, speech and language therapists, social workers, dietitians, physiotherapists and occupational therapists. Our main aims as a service are to control people’s symptoms, to improve their quality of life, provide care within their own homes where possible and achieve their preferred place of care and death.

A DIFFERENT KIND OF DIETETICS

I had visited the service during the application process for the role and was, therefore, well prepared for how the post may differentiate from working elsewhere. Firstly, it was expected that I would learn how to triage not only the dietetic referrals, but also the initial referrals for patients entering our overall service. This requires the person triaging to be able to look at the wider context of the patient’s care and establish their priorities within our service. The referral is checked for suitability and if it meets our referral criteria, a call is made to the patient or carer (and sometimes the referrer for additional information).

Following the call, we then link the referral through to the relevant members of the team who would benefit the patient most, in order for them to make contact to provide their interventions. As part of the triage role, we are each rostered onto different shifts, including evenings and weekends – another way in which this may differ from the typical dietetic post.

The second thing I was made aware of whilst applying for this role was that after further training and development, I would be expected to have discussions with patients regarding end-of-life and advanced-care planning. It was made clear to me that aside from the specialist dietetic input that I would be providing, I would have plenty of opportunity to further develop my skills of clinical assessment and progress as a clinician. This is a part of the role I am really enjoying, as these conversations often arise naturally as part of discussions surrounding reduced appetite, so it is worthwhile understanding how to structure these most effectively.

Claire Irlam Specialist Macmillan Dietitian, Manchester University NHS Foundation Trust Claire is a Specialist Dietitian within a Macmillan palliative care team and also volunteers as Chair for the North West England and North Wales Branch of the BDA.

REFERENCES Please visit: nhdmag.com/ references.html

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SKILLS & LEARNING

Having a multiprofessional team all based within the same office is invaluable for support and guidance and it offers the patient reassurance that issues can be promptly dealt with by the relevant team member.

IDENTITY CRISIS?

Something I find interesting within this post is how fluid my professional identity can be.

Although I am “the dietitian” within the team, I do not introduce myself as this when triaging incoming calls to the office, as callers often want a reassuring voice, someone who can answer their queries, regardless of professional background.

I also think of myself as more of a general clinician in situations where I am providing holistic support to patients. When unravelling their thoughts and feelings, or deciding on some aspects of advanced care planning, they are not seeking a dietitian but simply a willing listener from the Macmillan team.

It is also important to appreciate the differences in capabilities between our disciplines and provide a varied workforce on different shifts. For example, I would be rostered into the weekend rota as an allied health professional (AHP), ensuring that there is also a prescriber on shift and a variety of different levels of experience.

BENEFITS TO WORKING WITHIN AN MDT

One of the key benefits of working within an MDT is the advantage it provides to the patient in terms of continuity of care. Having a multiprofessional team all based within the same office is invaluable for support and guidance and it offers the patient reassurance that issues 38

can be promptly dealt with by the relevant team member. We start each day by discussing those patients we need to be aware of who have more complex care needs, and we also undertake regular caseload reviews. This daily communication can also prevent repetition within consultations from different visiting healthcare professionals. It also ensures that everybody is aware of each service user’s current priorities to help each patient achieve their goals and prevent them from feeling overwhelmed by conflicting interventions.

This is something which is implemented into my practice when I regularly undertake joint visits with my speech and language therapy colleague. This helps us within our professional practice, as we can learn from each other and it also saves time by preventing the need to liaise about patients afterwards.

It is helpful for the patient, as it reduces the number of consultations for them and ensures that there is no repetition of the questions being asked or conflicting information being provided.

Another advantage of being a dietitian based within an MDT is that there is reassurance that nutrition is always being advocated for within the caseload. It has allowed me to understand barriers that other clinicians experience when screening for malnutrition or providing first-line advice.

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SKILLS & LEARNING LESSONS LEARNED

One thing I often clarify to myself within this job is the subtle difference between extending your scope of practice and maintaining the boundaries of your own limitations. It can be all too easy when expanding your knowledge of different topics to be tempted to draw on these within consultations. I have found that through shadowing other members of the team and completing training sessions, I have a much better awareness of their roles and different aspects of the patient’s care. However, it remains important to refer onto the necessary healthcare professionals to manage certain aspects of treatment. For example, I am beginning to feel more comfortable exploring patients’ compliance with medications and tolerance of these, but should any changes need making following this discussion, a review from a prescriber would be required.

Another lesson I have learned is remembering that each member of the MDT has experience and skills within different areas and, therefore, the level of nutritional knowledge within the team may vary. I have completed training sessions with the team since commencing my role and plan to deliver more in the future, depending on which topics are relevant and of interest. I have also found it useful to complete joint visits with other clinicians and discuss patients with them, which has enabled them to build upon their understanding of different nutritional interventions. Similarly, I have learned a lot from other professionals, which has helped me build rapport within the team

and has also increased my knowledge of other aspects of patient care.

Whilst it can be time-consuming to attend meetings, it is really worthwhile to have a presence amongst relevant groups. Working within the community, I regularly meet with district nurses, general practitioners and hospital palliative care teams, as well as attend inter-service meetings with the other AHPs. This helps to increase the likelihood of care plans being implemented and relevant patients being referred.

Another potential challenge of working within an MDT is being the only dietitian. You can be expected to be approached regarding any nutritional issues and may be consulted as “the expert” on a variety of queries. It is, therefore, imperative to keep dietetic knowledge up to date with continuing professional development and to have an awareness of where further specialist dietetic guidance can be sought, such as creating links with nearby departments.

LOOKING TO THE FUTURE

Overall, I am really enjoying being based within an MDT and appreciate the variety provided by the role. I am looking forward to further developing the non-dietetic skills required to become a proficient member of the palliative care team, whilst continuing to ensure that the patients’ nutritional care is optimised. I would recommend undertaking a dietetic role within an MDT to those who wish to immerse themselves fully into a particular clinical area and are keen to increase their knowledge and competencies beyond nutritional care.

Suggested further reading 1 Gaertner et al (2017). Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis. British Medical Journal. 357 (2925) [online] available from www.bmj.com/content/357/bmj.j2925 [1 October 2020] 2 Manchester Health and Care Commissioning (2019). Macmillan Cancer Support announces further £5.2 million funding for end of life care in Manchester [online] available from www.mhcc.nhs.uk/news/macmillan-cancersupport-announces-further-5-2m-funding-for-end-of-life-care-in-manchester [1 October 2020] 3 National Cancer Action Team (2010). The Characteristics of an Effective Multidisciplinary Team (MDT).

London: National Cancer Action Team 4 NHS England (2014). MDT Development – Working toward an effective multidisciplinary/multiagency team. London: NHS England 5 Social care institute for excellence (2018). Delivering integrated care: the role of the multidisciplinary team [online] available from www.scie.org.uk/integrated-care/workforce/role-multidisciplinary-team [1 October 2020]

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IMD WATCH

PKU IN THE TIME OF COVID How have PKU patients been coping this year? Whilst many have had more time to deal with the low-protein diet, it is still a hugely difficult and time-consuming form of treatment to maintain.

During the COVID-19 pandemic, metabolic specialist dietitians Suzanne Ford Registered Dietitian have maintained regular, remote, contact with patients. In Suzanne is different ways, the resources at a Specialist Dietitian with the a patient’s disposal may have North Bristol NHS changed – sporadic food access Trust and Society in supermarkets, difficulties Dietitian (Adults) for The National in primary care getting preSociety for scription foods, but perhaps, Phenylketonuria (NSPKU). one thing patients may have is www.nspku.org more time available.

Six weeks into the first lockdown, 45% of the population was working from home; many people were ‘furloughed’ (and many still REFERENCES are); contracts paused or stopped, Please visit: and now we are seeing the nhdmag.com/ redundancies mounting up and references.html reports of businesses folding and shops closing down.

On the social media pages for groups and ‘feeds’ catering for people with PKU, we could see that low-protein baking and making food from scratch were being embraced by some for the first time, or by others to an extent never before established.

The only treatment (in the UK) for PKU is a complex lifelong regimen, with tighter control needed at different life stages.1 The diet is usually about 10g protein per day,2 and proteincontaining foods are either counted or measured down to 0.3g protein per serving. The complexity of the diet has evolved over 20 to 30 years and details have only just been agreed by specialists.3 As the diet depends upon restricting the phenylalanine (Phe) content of foods, it is necessary to plan, shop for ingredients, weigh foods and cook/prepare foods with great care.

Baking with low-protein products and no egg takes quite some skill and not everyone acquires the ability. The time commitment needed for a low-protein diet is considerable.

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TIME NEEDED FOR PKU TREATMENT

Peer-reviewed evidence4 shows that the time needed for PKU management is approximately 13-19 hours per week, which includes: • food Research and cooking from scratch/ baking bread = 9 hours; • weighing foods = 1.75 hours; • protein-intake note-keeping = up to 1.5 hours; • managing prescriptions and blood testing/ posting blood tests = 1 hour; • in children/young people, taking protein substitutes = 5 hours.

The above relates to people who did not have impaired intellectual or executive functioning.

In individuals with impaired neurocognitive functioning (a recognised side complication of undertreated PKU5), the time taken to manage the diet is longer. Further evidence shows that, in order to achieve the best health outcomes for adults self-managing their PKU, part-time working and flexible working patterns are best.6 Social isolation is another key aspect of lockdown. In a peer-reviewed paper7 reporting on life with PKU from an online survey run by the NSPKU, almost half of parents and caregivers (51% [n=120/236] and 44% of adults (n=126/286)] described social exclusion because of the diet. From the theme of social isolation, respondents identified this as a source of upset, frustration, embarrassment, and a major barrier to adherence and how it made them feel different from their friends and colleagues.

As the government prepares to ease us out of lockdown for a second time, I hope that those who have gained new self-management skills in low-protein cooking, researching, planning and executing complex treatment regimens, continue to do so. However, these questions must be asked: is 13+ hours a week on self-management sustainable lifelong in our modern world and should the NHS invest in modern treatments (available outside the UK), for rare disease patients?

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CLINICAL

ENHANCED RECOVERY PRE- AND POSTOPERATIVELY Numerous factors influence recovery after surgery, including underlying disease, extent of surgery, age and psychological wellbeing. However, nutritional intervention can play an integral role, as the correct nutrition is an essential part of the recovery process.

For any patient undergoing surgery, recovery and avoidance of complications are key objectives. The pre- and postoperative health and diet of the patient is an integral part of this. Malnutrition can negatively affect wound healing by prolonging inflammatory pathways, and in patients with undernutrition who present for surgery, there is a higher risk of postoperative complications including morbidity and mortality.1,2 GUIDELINES AND PATHWAYS

Hospital stays are shorter, postoperative complications less frequent and overall costs lower when people who have elective major or complex surgery follow an enhanced recovery programme (ERP).

Recent NICE guidance recommends that an ERP should cover all three stages of surgery: preoperative, intraoperative and postoperative, but that the specific components of an ERP depend on the type of surgery.3 ESPEN guidance recommends that nutrition support should be used in patients with severe nutritional risk 10-14 days prior to surgery; inadequate oral intake during this period is associated with a higher mortality.4 For those patients at severe nutritional risk, a delay to surgery and administration of tube feeding and/or oral nutritional supplements (ONS) is advised (with exception to intestinal obstruction, severe shock and intestinal ischemia).

Use of tube feeding and/or ONS is also indicated in those patients who cannot maintain oral intake above 60% of recommended intake for more than 10

days and those who will be unable to eat for more than seven days perioperatively (even if undernutrition is not obvious).

Parenteral nutrition (PN) is indicated in patients for whom enteral nutrition (EN) may not be appropriate, such as in intestinal obstruction or failure.4 PN can also be used to complement EN, in those patients consuming <60% of calorific requirements. In upper GI cancer patients at severe nutritional risk, use of PN preoperatively has been shown to reduce complications.5 ESPEN guidance on clinical nutrition in surgery6 states that: â&#x20AC;&#x2DC;Early oral feeding is the preferred mode of nutrition for surgical patients.

Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery.â&#x20AC;&#x2122; BAPEN provides resources and guidance on combatting malnutrition and also provides a toolkit for commissioners.7,8

Naomi Brown Scientific and Regulatory Manager, BSNA Naomi has a First-Class Honours degree in Nutritional Science and an MSc in Public Health Nutrition.

She has worked in the nutrition industry for several years.

REFERENCES Please visit: nhdmag.com/ references.html

PREOPERATIVE CONSIDERATIONS

The overall health and nutritional status of the patient prior to surgery will vary significantly. Underweight, malnutrition and low muscle mass may already be present pre-surgery due to aging (sarcopenia), disease (cachexia) and inactivity (atrophy).9 www.NHDmag.com December 2020 / January 2021 - Issue 159

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CLINICAL

The ERAS programme considers key nutritional and metabolic aspects of pre- and postoperative care, which integrate nutrition into the overall management of the patient.

Surgical nutrition studies have identified weight loss (>10%) and low albumin (<30g/l) as risk factors for adverse outcomes.10 Skeletal muscle plays an essential role in health; loss of aerobic capacity, reduced strength, weakness, fatigue, insulin resistance, falls and fear of falling, frailty, disability and mortality are all associated with skeletal muscle loss.11 An interruption in nutritional intake can be negatively implicated in health outcomes; increased metabolic stress, hyperglycaemia and insulin resistance are all indicated in preoperative fasting.4,12 Therefore, whilst preoperative fasting is still common practice, it is now considered unnecessary for most patients (although this is contraindicated in those at risk of aspiration).

When an earlier return to gastrointestinal function is facilitated, patientsâ&#x20AC;&#x2122; tolerance to normal food and even enteral feeding can also be improved.13 In a systematic review of patients who had elective gastrointestinal surgery, septic complications and length of hospital stay were reduced in those who received early EN.14 It should be noted, however, that risks are associated with both enteral feeding and its early use. BAPEN guidelines provide advice on best practice for the administration of medication via enteral tubes.15 Surgery can have a huge impact on the body, resulting in a cascade of metabolic changes.

When an injury occurs, afferent neuronal impulses activate an endocrine response.16 This stress response to surgery results in a rise in stress hormones and inflammatory markers, which present as immune system suppression and increased cortisol secretions, which will impact carbohydrate, fat and protein metabolism.

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Insulin resistance is a sign of surgical stress, with more extensive surgery associated with greater levels of insulin resistance â&#x20AC;&#x201C; an independent risk factor that influences length of stay and poor wound healing.17 Hormonal changes will lead to increased catabolism (to mobilise energy sources). Once surgery has commenced, blood glucose concentrations will rise: the extent of this varies according to the type and degree of surgery. Potential risks of perioperative hyperglycaemia are linked to wound infection and impaired wound healing. Postoperative control of blood sugar levels is, therefore, essential to recovery and overall outcomes.

POSTOPERATIVE CONSIDERATIONS

During periods of inactivity/immobility, such as post-surgery, a loss of lean body mass is implicated in a reduced ability to recover.

This issue is further exacerbated with age. An older cohort subjected to 10 days of inactivity experienced approximately a three-fold greater loss of lean leg muscle mass when compared to a younger cohort examining protein synthesis and muscle mass in healthy adults who were subjected to bed rest for 28 days.5,18 From age 40, muscles do not respond to protein from the diet as well as that of younger counterparts.19 The right nutrition for muscle health and recovery is, therefore, key.

Postoperatively, for the majority of patients a standard whole protein formula is appropriate, which may include immune-modulating substrates (arginine, omega-3 fatty acids and nucleotides) in enteral form.4 Extensive research exists on the role of ONS in older populations, which has shown to increase both body weight

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CLINICAL and improve nutritional status.20 In those older individuals who are malnourished, an ONS high in protein and vitamin D in particular, can have a valuable role to play in improved recovery.

Patients with whole-body protein depletion have been shown to have a marked increase in both major complications and duration of postoperative stay.21 For both young and elderly individuals it is well researched that moderateto-large servings of protein or amino acids increases muscle protein synthesis.22,23 In older adults, high doses of protein (>25g) or essential amino acids (10-15g) have a similar ability to synthesise muscle protein compared to younger ones; lower doses (protein <20g; EAAs <8g) do not achieve the same skeletal muscle response.

However, single servings of >30g protein do not stimulate a greater anabolic response between younger and older adults.24 ASPEN25 has suggested 1.2-2.0g protein/kg for those in the critical care setting, including postoperative major surgery.25 In a prospective non-randomised study, significant reductions in nosocomial infections and overall complications were shown in highrisk surgery patients (NRS 2002 ≥5) who received sufficient preoperative nutrition therapy (>10kcal/kg/d for seven days) when compared with patients who received insufficient therapy.26 For low risk patients, no differences were observed between sufficient and insufficient EN.6 ‘Immune modulating nutrition’ or ‘immunonutrition’ (a liquid nutritional supplement enriched with specific nutrients), given by the oral/ enteral route during the perioperative period has demonstrated a reduction in postoperative infective complications.27 Optimal rehabilitation and wound healing are dependent on the body being in an anabolic state.

For the majority of patients undergoing surgery, a preoperative carbohydrate drink the night before (800ml) and a 400ml drink two hours prior to anaesthesia is generally advised.4 Reduced postoperative insulin resistance and preservation of skeletal muscle mass has been demonstrated in colorectal patients and those with hip replacement who took a 12.5% hypo-osmolar carbohydrate rich drink preoperatively.28,31 Additionally, preoperative carbohydrate loading reduces thirst, hunger and anxiety.29,30The correct preoperative

preparation is essential to postoperative recovery; carbohydrate loading reduces insulin resistance and diminishes nitrogen and protein loss.32,33 Postoperatively it also helps to preserve skeletal muscle.

ERAS PROTOCOLS

Enhanced recovery after surgery (ERAS) protocols and guidelines have become a widely accepted toolkit adopted by a number of hospitals.34 These protocols provide evidencebased recommendations for ONS and EN in surgical patients. The ERAS Society provides a list of pathways and guidelines on their website: www.erassociety.org/guidelines/listof-guidelines.

ERAS guidelines seek to minimise surgical stress, maintain nutritional status, reduce complications and optimise recovery rates. The ERAS programme considers key nutritional and metabolic aspects of pre- and postoperative care, which integrate nutrition into the overall management of the patient, and include:35 • preoperative nutrition; • avoidance of long periods of preoperative fasting; • fluid intake and carbohydrate loading up to two hours preoperatively; • re-establishment of oral feeding as early as possible after surgery (ideally the first postoperative day); • metabolic control, eg, of blood glucose; • reduction of factors which exacerbate stressrelated catabolism or impair gastrointestinal function.4 Successful adoption of an enhanced recovery approach also requires input from the multidisciplinary team; ‘enhanced recovery is about the whole team rather than an individual’ at a sustained level.36 CONCLUSION

Implementing the most appropriate pre- and post-surgery protocols ensures that patients have the best possible chance of a successful and speedy recovery. Nutritional screening and intervention can play a vital role in this, with ERAS programmes offering a measured clinical impact on overall patient outcomes.

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F2F

FACE TO FACE Ursula meets: JULIE LANIGAN Childhood nutrition researcher Director of Trim Tots CIC Ursula Arens Writer; Nutrition & Dietetics

BDA Paediatric Group Vice-Chair

Never make assumptions. Julie said, “Actually no,” when I suggested the usual hurdle into dietetics: chemistry & biology A-Levels. She had three children in her early 20s. She also spent many years working in the Marketing department of Watford Football Club.

Perks included tickets to matches and parties at the home of the then Chairman, Our F2F Elton John (now Life-President).

Julie’s family are vegetarian. Her interviews search for healthy recipes developed feature people into an interest in nutrition. “I read who influence several books, including the classic green MAFF Manual of Nutrition,” nutrition she told me. She then set up a policies vegetarian café, one of the first of its and practices kind, and extended her wares to local businesses. Julie recognises the huge in the UK. support she enjoyed from friends and family, which also allowed her to take on the additional challenge of those A-levels.

She then worked for two years as a medical representative, supporting promotion for gastrointestinal drugs. In the early 90s, the links between helicobacter pylori and stomach ulcers were known by gastroenterologists, but less familiar to other doctors, and Julie became a gut expert. “I enjoyed the hospital environment and decided that dietetics would be the perfect career for me.”

Again, friends and family offered support and encouragement. The first year of the University of Surrey course was a challenge, but the later years and placement were really enjoyable. So, in 1997, she started her first dietetic post Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She enjoys the gifts of Aspergers.

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at Northwick Park Hospital. “I worked in lots of departments, but particularly enjoyed paediatrics,” said Julie.

She was contacted by Jackie Bishop, head of the Dietetics course at Surrey.

Would she be interested in doing a research project that looked at links between infant health and timings of weaning? Of all the possible dietetic graduates, I wondered why Jackie approached Julie. “Perhaps I was the most mature?” suggested Julie. (My thought: because she had great research skills and attitude.)

As is the way, the research needed more time, and new projects were bolted onto original questions. Julie was invited to join the team at the Institute of Child Health (ICH), and became the lead for a bigger project, looking at the validation of food diaries for assessing dietary intakes of infants (matched to doubly-labelled water data).

Julie was now at the centre of research expertise looking into child health. She became involved in many of the projects studying the modifiable factors affecting infant growth rates.

The epidemiologist Professor Barker had observed correlations between low birth weight and adult chronic disease risks, and later projects suggested that while pregnancy-linked factors to birth weight were less modifiable, growth rates in early infancy may also programme metabolism linked to disease risk in later life. Some of these differences could already be detected in later childhood.

F2F

Julie spent many years looking at breastfed versus high- or low-protein formula-fed infants.

Higher protein intakes were linked to faster growth rates, but with concerns of greater risks of future obesity and disease. Her research contributed to recommendations that growth promotion was not advisable in healthy infants.

Growth charts released by WHO in 2006, revised data obtained from only breastfed babies (rather than formula-fed), resulting in lower weight and length projections.

Of course, breastfeeding is best. Data show slight improvements in the UK in the last decade, but general rates are lower than in many other European countries, with less than one in five mothers breastfeeding at three months. “There are many cultural factors to explain these disappointing data, but much more should be done to support and encourage mothers in the first few weeks after birth,” commented Julie. But choices to breastfeed or formula feed are delicate and linked to many personal and private circumstances.

“Thanks to nutrition research, it is beyond doubt that breastfeeding is best for most infants, but infant formulas are much improved products today compared with decades ago,” she continued.

Julie completed her PhD in 2012. Her project was part of a randomised controlled trial in young people, looking at high dose docosahexaenoic acid (DHA) supplementation versus placebo on markers of vascular health linked to cardiovascular disease risk. Julie assessed dietary intakes of DHA from food diaries, noting that it was the first study to send text message reminders to subjects. The results were unexpected: DHA did lower triglyceride levels but did not improve measures of endothelial function.

Great Ormond Street Hospital is ‘next door’ to ICH, and Julie became interested in the nutritional status of children with HIV. “Some effects are due to the disease; some effects are due to the medication, and some issues relate to misinformation and confusion about diets and supplements,” she said. Julie became an active volunteer for a South African charity and took many trips as part of a multidisciplinary team, to advise on the nutritional management of affected families and children.

One of her current projects is the development of a community interest company communicating healthy lifestyles to families with preschool children: Trim Tots. The 24 weeks of creative activity sessions for under-fives at risk of overweight, showed great outcomes (lower BMI, waist circumference and other obesity risk factors). “Obesity is difficult for children and difficult for their parents too. It is complex and linked to many environmental factors, but prevention and early intervention seem the best way to reduce the risk of later ill health,” said Julie. But despite plaudits and evidence of successful outcomes, funding has been tight and enthusiasm from academics and politicians has yet to translate into financial support for Trim Tots. So, if you are a fundholder, reading this . . .

Julie is currently Vice-Chair of the BDA Paediatric Group. She has quiet confidence and is part of the A-team asking the biggest questions about the feeding of the littlest people. But we all make assumptions. Perhaps her success is linked to her back-to-front career: having three children at a young age must have given her deeper insights into the practicalities of baby and toddler diets than any academic texts can offer.

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EVENTS & COURSES ROYAL MARSDEN VIRTUAL STUDY DAY – SWALLOWING AND COMMUNICATION 25th & 26th February 2021 Cost: £100 (£50 per session)

This event will equip healthcare professionals with the foundation skills for the management of communication and swallowing disorders which arise as a result of an oncological diagnosis or treatment(s) received. www.royalmarsden.nhs.uk/swallowing-communication-virtual-study-day DYSPHAGIA FOR SPEECH & LANGUAGE THERAPISTS Day 1: Focus on Diagnostics, Day 2: Focus on Rehabilitation 18th-19th January 2021 www.ncore.org.uk/Website_Event_Details?eventid=2740 MANAGEMENT OF CHRONIC KIDNEY DISEASE STAGE 3-5 11th February 2021 Online via MS Teams. BDA Trainer: Fiona Willingham www.ncore.org.uk/Website_Event_Details?eventid=2834

INTRODUCTION TO DIETARY MANAGEMENT OF ADULTS WITH INFLAMMATORY BOWEL DISEASE Increase knowledge and skills in the nutritional care of adults living with IBD. 12th February 2021 Online via MS Teams. BDA Trainer: Dr Kirsty Porter www.ncore.org.uk/Website_Event_ Details?eventid=2836

www.nhdmag.com/events.html

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The NHD Blog – comment and opinion from our authors.

KEEP YOURSELF UP TO DATE, whether you’re at home, work or on the move. Our regular bloggers cover a range of nutrition-related topics, providing insight, tips and advice and thoughtful debate. There’s also an opportunity to join the conversation too; you can share your comments on the blog post and if you would like to submit a blog, do get in touch: info@networkhealthgroup.co.uk

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GOODBYE 2020!

Louise Robertson Specialist Dietitian

So long 2020! Most of us will be glad to see the back of you. Writing this post has made me reflect on how 2020 has turned out to be very different from what we had hoped or expected. It has certainly been been different; it has seen many changes; it has seen new ways of working; it has created a new normal.

From a nutrition point of view, 2020 has definitely changed our shopping and eating habits. At the beginning of the year, the predicted food trends were more plant-based eating, mocktails, alternative flours and CBD oil! In reality, the food trends became eating at home, cooking from scratch, shopping locally and baking banana bread! These have been some good things to have come out of the lockdowns and restrictions we have had to face.

Many of us have had time to enjoy cooking and baking. We have had more time to cook from scratch with fresh produce and eat meals as a family at the table. Many of us have supported our local shops by using the greengrocers or butchers more often than we used to and both my veg box and milk delivery have been invaluable.

But letâ&#x20AC;&#x2122;s not forget the people who have struggled in 2020. The Trussell Trust website report that over 50% of

people using food banks at the start of the pandemic had never needed to use one before. Sadly, they have found that families with children are being worst hit during the crisis. They are expecting to provide six emergency food parcels every minute as winter approaches.

For those of us who can survive and cope well during these unprecedented times, with a roof over our heads and food on the table, we should think about how we can we give back in 2021 to those who are not so lucky. Can we pop some food in the food bank trolley at the supermarket? Can we give to food bank charities or even volunteer our time?

So, to end this strange 2020 year, our Christmas dinners will be a quieter affair than usual, but I hope, for most of us, they are full of lovely home-baked goods and produce from our local shops. Wishing you all a happy, healthy and safe festive season. Louise

Louise is an experienced NHS dietitian who has been specialising in the fascinating area of Inherited Metabolic Disorders in adults for the last 10 years. In her spare time she enjoys running her blog Dietitianâ&#x20AC;&#x2122;s Life with her colleague and good friend Sarah Howe, playing the cello and keeping up with her two little girls! www. dietitianslife.com

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