Network Health Digest March 2021 by NH Publishing Ltd

– ED D M R NH FO R IN FO AY CH ST EA R

The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

March 2021: Issue 161

THE LOW-FODMAP DIET FOR IBS

COVID-19 IMPACT: – NUTRITIONAL CONSEQUENCES – HISTAMINE INTOLERANCE – MALNUTRITION NASOGASTRIC FEEDING DIABETES & INTUITIVE EATING PAEDIATRIC FOOD ALLERGY CHOLESTEROL NUTRITION & HYDRATION IN THE ELDERLY

The history of tube feeding Page 25

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. Isosource® Junior Mix contains 13.8% food derived ingredients (rehydrated chicken meat & rehydrated vegetables, peach puree, orange juice from concentrate).

ᵻ

For Healthcare Professional Use Only. ®Reg. Trademark of Société des Produits Nestlé S.A. 02/2021. Isosource® Junior Mix is a food for special medical purposes for use under medical supervision.

UP FRONT Welcome to this March issue of NHD. We are fast approaching the 12-month anniversary of the start of lockdown due to the coronavirus pandemic. A year ago, the UK Government imposed a stay-at-home order with the oftrepeated message, “Stay Home, Protect the NHS, Save Lives”. Since then, the restrictions have become our new normal. Whilst the pandemic has changed the way we do things, awareness events have still taken place throughout the year. The electronic era we live in has meant that, as well as taking our favourite yoga classes online, we can also spread and highlight important messages and build online communities. A huge amount of mental health and wellbeing communication has been shared this way throughout the pandemic, and digital media has become the go-to method for campaigners and supporters alike. When you receive this issue, you’ll have just missed Eating Disorders Awareness Week (EDAW). An international event, EDAW aims to fight the myths and misunderstandings that surround a wide range of eating disorders (EDs). This year’s theme focused on binge eating disorder, aiming to create a future where people experiencing this debilitating condition are met with understanding and compassion. One in 50 people will be affected by binge eating disorder at some point in their lives – it’s the most common ED, but the least understood. Just one in four people receive the care they need to recover from it. BEAT say, ‘It isn’t about being greedy or lacking in willpower, but a serious mental illness which many suffer with alone, often with the fear of how others might react, being the reason they don’t reach out for help.’ This is the first time BEAT have used EDAW to focus on a specific type

of ED. They made this decision based on the trends they were seeing via their helpline: ‘In November 2020, 29% of contacts to BEAT’s Helpline were about binge eating disorder, but only 6% of the media coverage we generated in the last year spoke specifically about binge eating disorder.’ This is a new avenue for BEAT to pursue, with much to gain. Read and watch more about this year’s campaign here: https://www. beateatingdisorders.org.uk/edaw. With EDAW in mind, Oana Oancea joins us this issue, with her article on tube feeding in adults with eating disorders, where she discusses the current guidelines and protocols. You’ll find Bogna Nicińska’s article on the history of tube feeding fascinating too. It’s a must-read! As always, this month’s NHD offers a varied patchwork of reading for you, including our Cover Story on the low-FODMAP diet considerations for patients with IBS. This diet isn’t always suitable and Frances Ralph discusses alternative methods of symptom management. Diet and ED themes run through Eloize Kazmiersky’s article on intuitive eating and Type 1 diabetes (T1D), where she demonstrates how T1D management can lead to disordered eating behaviours and provides a consensus on how intuitive eating could help with this. And, of course, there’s a whole lot more to read and digest. Emma

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

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11 COVER STORY The low-fodmap diet for IBS 6

News

37 PAEDIATRIC FOOD ALLERGY

Latest industry and product updates

COVID-19 8 Nutritional consequences 15 Histamine intolerance 19 Malnutrition 25 Adult tube feeding Then, now and

41 Nutrition & hydration Care of the elderly

44 CHOLESTEROL

47 F2F Interview with Belinda Mortell

in the future

28 NASOGASTRIC FEEDING & ED

key questions

54 Events & courses Details, dates and NHD resources

33 Type 1 diabetes Managing with

50 Student resources Advice on tackling

55 Dietitian's Life Losing taste and smell with COVID-19

intuitive eating

Copyright 2021. 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

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BARIATRIC SURGERY REDUCES COVID-19 SEVERITY In recent months, researchers have identified obesity as a risk factor for developing more severe COVID-19, which may require hospital admission, time in intensive care and ventilator support. But a new study published in Obesity Surgery, has found an association between bariatric surgery and clinical outcomes for COVID-19, suggesting that previous weight-loss surgery could affect the severity of outcomes. The systematic review looked at 9022 patients from three retrospective studies. Researchers looked at hospital admissions in those with COVID-19, as well as the risk of mortality in those who have had bariatric surgery versus those who had not. Results showed a significantly lower risk of hospital admissions in those who had previously had bariatric surgery, compared with those who had not. There were also fewer cases of mortality in those who had previously had bariatric surgery. These results suggest that previous bariatric surgery is associated with a lower rate of mortality and hospital admissions in patients with obesity who became infected with COVID-19. However, there was a risk of bias in this study for confounding and selection. Larger studies are, therefore, needed with better quality data. For more information, visit: https://link.springer.com/article/10.1007/s11695-020-05213-9

PROMOTIONS OF UNHEALTHY FOODS RESTRICTED FROM APRIL 2022 The UK Government has outlined a plan for a ban on the promotion of food and drinks high in fat, salt or sugar in retailers, both instore and online from April 2022. The new rules come following the antiobesity strategy of July 2020. The restrictions have been designed to support the nation into making healthier food choices. What do the new measures include? • Retailers will be prohibited from offering multibuy promotions such as ‘BOGOF’ or ‘3 for 2’ on unhealthy products. • Stores will not be allowed to feature unhealthy foods in key locations. • Free refills on soft drinks will be prohibited in the eating-out sector. • Restrictions apply to medium and large stores (over 2000 square feet). More information at: www.gov.uk/government/news/promotions-of-unhealthy-foods-restrictedfrom-april-2022

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NEWS SACN STATEMENT ON NUTRITION AND OLDER ADULTS The Scientific Advisory Committee on Nutrition (SACN) has recently released a statement on nutrition and older adults living in the community and the impact on healthy ageing. The last report of this nature was carried out by COMA back in 1992. Since then, the UK population has changed dramatically and there is an increasing number of older adults, with one in five people now aged 65 years and over. The statement reports on the National Diet and Nutrition Survey (NDNS) and provides an overview of the evidence up until February 2019. It reports that adults aged 65 to 74 and 75 years and over exceeded maximum recommendations for intakes of saturated fat, free sugars and salt. They also failed to meet the recommendations for fruit and vegetables, fibre and oily fish. Not dissimilar to the trend of the overall UK population. In terms of nutritional status, the statement shows some evidence for low micronutrient intakes of vitamin D and folate, particularly in women aged 75 and over. SACN also looked at BMI using the NDNS data and found that a high percentage of older adults were living with overweight or obesity, with 87% of men and 68% of women aged 65-74 living with overweight or obesity. In contrast, the prevalence of underweight in older adults was low: just 7% of men and 3% of women aged 75 years and over. In those aged 65-74, less than 1% of men and 3% of women were underweight. To check out the full report, go to: www.gov.uk/government/publications/sacn-statement-on-nutrition-and-older-adults

FOOD PATTERNS PARTLY DOWN TO GENETICS A recent study at King’s College London has shown that food intake patterns are partly due to our genetics.1 The study, published in the journal Twin Research and Human Genetics, was the first comprehensive investigation looking into the contribution of genes and the environment on the variation of dietary indices. The responses of food frequency questionnaires (FFQ) from 2590 female twins, including both identical and non-identical twins, were analysed. Results showed that identical twins were more likely to have similar scores across dietary indices, compared with non-identical twins. This was also the case when other factors, such as body mass index and exercise levels, were taken into account. This study suggests that food and nutrient intake, as measured by nine dietary indices, is also partly under genetic control. As the study looked at female twins only, with an average age of 58, future research is needed to look at a more varied population to see if the findings are similar. 1 Mompeo O, Gibson R, Christofidou P et al (2021). Genetic and Environmental Influences of Dietary Indices in a UK Female Twin Cohort. Twin Research and Human Genetics,1-8. doi:10.1017/thg.2020.84

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COVID-19

NUTRITIONAL CONSEQUENCES OF THE COVID-19 PANDEMIC

Ruth James RD MSc SENr MBA Ruth was previously a Clinical Gastro Dietitian and NHS Manager. She is now a Registered Sports Nutritionist who is passionate about helping elite and recreational sports people realise their full performance potential.

REFERENCES Please visit: nhdmag.com/ references.html

Nutrition has been recognised as an important factor in the context of the COVID-19 pandemic, with obesity seen as a key risk for severe illness. The implementation of restrictive public health measures has increased the challenges facing healthy eating, physical activity and mental resilience. This article explores these key nutrition themes, which are often interrelated. The impact of poverty from job and economic uncertainty and the effect of school closures on children’s food intake, have been highlighted during the pandemic. The crisis has also emphasised the critical role of nutrition in immune health. Dietitians and nutritionists are in a pivotal position to address these issues, either in a clinical setting in ITU or in long-COVID clinics, by influencing and helping the disadvantaged and advising food providers. Tackling misinformation in the media is another key issue we can try to address. OBESITY

One of the risk factors for severe COVID-19 is obesity (a Body Mass Index >40). A meta-analysis of 75 international studies examined the association of excess weight across the COVID-19 spectrum, from infection to death. It found that individuals have more than double the likelihood of going into hospital if they are obese and 50% more likelihood of dying. This may be due to the impact of overweight on cardiorespiratory and lung functioning, as well as on immune dysfunction. Obesity can also influence the development of hypertension, diabetes, stroke, atrial fibrillation, kidney and liver diseases and overall heart failure. These comorbidities cause reduced pulmonary function, functional capacity and respiratory

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system compliance, along with reduced β-cell functioning and increased insulin resistance. These can limit proper immune responses to viral exposures and increase a patient’s difficulty responding to common COVID-19 therapy such as ventilatory support. The lockdown during the first wave of the pandemic is known to have already led to quarantine weight gain, so it is expected that we will see another negative impact during the second and third waves. Moreover, mental health issues have been exacerbated in both overweight children and adults, due to self-isolation, disruption of usual weight control strategies, stress and stigmatisation. This has focused a spotlight on obesity as a global health problem, along with the associated risks of deprivation, poverty and ethnicity. For more on the impact of COVID-19 on obesity see Emma Berry’s article in NHD February, issue 160, p8. THE IMMUNE SYSTEM AND COVID-19

Whilst attention has focused mainly on vitamin D in enhancing the immune system and reducing the risk of infections, other vitamins, trace elements, amino acids and fatty acids have also been implicated. Vitamin D, zinc and selenium seem to be particularly important in antiviral immunity. Immune cells

COVID-19 have the vitamin D receptor, some immune cells produce the active form of vitamin D, and vitamin D, zinc and selenium all support antigen presenting cells, T cells and B cells to function. Zinc has been shown to inhibit the RNA polymerase required by RNA viruses, like coronaviruses, to replicate and spread. Clinical deficiencies in zinc and selenium compromise the immune system and can increase the rate of infection. Zinc supplementation has been shown to decrease risk of mortality with severe pneumonia in some settings. Limited emerging evidence suggests low zinc or selenium status could be linked to more severe COVID-19, but more research is needed. Low vitamin D status is associated with increased risk of COVID-19 infection, as well as hospitalisation. Observational data show that up to 80% of people admitted to hospital with COVID-19 are deficient in this vitamin compared with 20% in the population. Interestingly, vitamin D deficiency is also more prevalent in individuals living with overweight and obesity compared with individuals of normal weight. Some research suggests that deficiency prevalence is 25% to 35% with overweight and obesity. The complications of obtaining sufficient vitamin D are further exacerbated by the global quarantines, isolation and stay-at-home orders. For many, especially older individuals in nursing homes, as well as for ethnic minorities who more commonly live in densely populated areas, these measures include little or no movement outside their homes. When combined with the typical Western diet high in processed foods that lack vitamin D, these restrictive lockdown measures can impair one’s ability to obtain sufficient vitamin D needed to maintain or boost immune functioning. This, in turn, could reduce the ability to prevent or fight COVID-19 in susceptible individuals. Currently, there is a lack of scientific evidence to recommend vitamin D for prevention of COVID-19, but research is ongoing. As a precaution, to ensure good bone and muscle health, and in consideration of more limited exposure to sunlight in the pandemic (due to isolation), vitamin D supplements for the general population are recommended

(400 IU [10 µg] per day), particularly in winter months, with caution against doses higher than the upper limit (4000 IU/d; 100 µg/d). There may be an association between seasonal upper respiratory tract infections and low vitamin D status. In a recent systematic review and meta-analysis of individual participant data from randomised controlled trials, vitamin D supplementation reduced the risk of acute respiratory tract infections (ARTI). However, there is a great deal of heterogeneity in these studies. RACE AND ETHNICITY

Recent reports suggest that racial and ethnic minorities have experienced an increased rate of infection, as well as a disproportionate amount of negative COVID-19-related outcomes compared with white individuals. The increased risk of COVID-19 transmission continues to highlight the health disparities experienced by these minority groups and can be related to social determinants of health, socioeconomic and educational input; healthcare access; racial discrimination and biological factors. Biologically, racial and ethnic minorities experience a higher rate of comorbidities that may negatively affect COVID-19 outcomes, including morbid obesity, cardiovascular diseases, diabetes, liver and kidney diseases and HIV and respiratory issues including asthma and chronic obstructive respiratory disease. Factors that may cause disproportionate vitamin D deficiency in darker-skinned individuals include reduced ability to synthesise vitamin D from the skin because of the darker pigmentation, as well as reduced levels of vitamin D-binding protein, which transports vitamin D in the body for activation and functioning. FOOD INSECURITY AND POVERTY

The coronavirus pandemic has led to food shortages, increased food prices and loss of income for many. Uncertainty around BREXIT negotiations and the economic fallout have complicated issues further. The lack of consistent access to nutritious food sources is associated with chronic physical and mental health problems. www.NHDmag.com March 2021 - Issue 161

COVID-19 Food banks have seen exponential growth in need over the last year. Child hunger remains a huge issue – over a million new schoolchildren signed up for free school meals last September, bringing the total to 2.5 million. EMOTIONAL AND PSYCHOLOGICAL PROBLEMS

Working at home, home schooling and childcare, job insecurity and the threat of COVID-19 itself, have all caused an increase in mental health issues in the general community, with even harsher effects experienced by people with existing mental illnesses and mood disorders. The pandemic has had especially “strong and wide-ranging” effects on people with anorexia and bulimia nervosa, for example when people stockpile high-risk foods out of fear of food supply disruption, people with bulimia face intense urges to binge. Anxiety around food availability can also be a triggering environment for individuals with eating disorders, creating an urge to starve, while lack of social support and the inability to access food consistently can disrupt regular meal plans. Studies on food insecurity and eating pathology have heightened concern about the impact the added effect of the pandemic may have on the eating behaviours of children and adolescents. SHOPPING AND CONSUMER BEHAVIOUR

The pandemic has acted as a catalyst for online growth and home delivery for food products and this is set to continue. Online grocery doubled its market share in December 2020. More than six million households in the UK tried online shopping last year, largely due to the physical restrictions in place. Shopping online may become the new norm. Also, the pandemic has made people focus on things which will make them feel they are contributing more to the welfare of the planet and “food with a purpose”. Local foods that have a story and are environmentally friendly are on the rise. More consumers want to know where their food comes from and how it impacts not only their 10

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health, but the health of their communities and the environment. Convenience is still important and home meal kits and fresh food delivered to your door will continue to grow in demand. Companies will not only try to make nutritious food more accessible, but they will be more open and transparent about what ingredients they use and how their food is prepared. The coronavirus pandemic has had a significant impact on consumer eating habits. More convenience products and canned foods with longer shelf lives are being purchased. The consumption of alcohol and confectionery has also increased, but the consumption of fresh fruit and vegetables has declined. THE IMPACT OF BREXIT

Although about 52% of the UK’s food needs are currently met by domestic production, the remainder is heavily dependent on imports from European Union countries. The UK’s reliance on the EU is especially acute in the horticulture sector, with about 40% of vegetables and 37% of fruit sold in the UK being imported from EU countries. At this time of year, outside of the British growing season, the country’s dependence on Europe is even more stark, with practically all of UK tomatoes, lettuces and soft fruit coming from the Netherlands and Spain. Because affordability is the major determinant of consumer behaviour, food price inflation is likely to drive down demand for fruit and vegetables – especially by low-income households. END NOTES

The impact of COVID-19 has caused a lot of interest in foods that can positively affect health, such as immunity boosters and foods to combat stress. Dietitians and nutritionists should capture this momentum, as they have a huge role to play in providing the evidencebased facts and advising on the treatment of obesity during and beyond this pandemic. More research is needed to investigate the impact of vitamin D supplementation and other antioxidants on COVID-19 risk and disease-related outcomes in otherwise healthy individuals.

COVER STORY

THE LOW-FODMAP DIET: CONSIDERATIONS AND ALTERNATIVES The low-FODMAP diet has become a key dietetic intervention for the management of IBS, which affects 11% of adults.1 This article summarises what’s involved in the low-FODMAP diet and outlines some alternative therapies to consider when the diet is inappropriate for an individual. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols. It involves a three-stage approach to symptom management: 1 Restriction (where FODMAP intake is minimal) 2 Reintroduction (where FODMAPs are reintroduced to individual tolerance) 3 Long-term maintenance (where individual tolerance levels are adopted and tolerated FODMAPs are consumed again) Clinical studies show that a lowFODMAP diet can significantly improve gastrointestinal symptoms, abdominal pain and quality of life in people with IBS.3 In fact, as many as 50-80% of people with IBS achieve adequate symptom relief following a low-FODMAP diet.4 FODMAPs draw water into the small intestine via osmosis and are fermented by gut bacteria in the large intestine, which can lead to IBS symptoms such as diarrhoea, wind, bloating and abdominal pain.4

Frances Ralph RD

The BDA guidelines state that the low-FODMAP diet is a secondline intervention that should be used following first-line advice to control symptoms.5 First-line advice should cover general healthy eating and lifestyle, limiting gut stimulants such as caffeine, fat and spicy foods, along with fibre modification based on the individual’s symptom profile and current diet.5,6 Clinical use of the diet has increased significantly since its inception at Monash University, Australia in 20042 (following years of research into the individual components of the diet). However, it is important that nutrition professionals are aware of potential downsides of this diet,7 and that IBS management is not a one-size-fits-all intervention.

Frances is an experienced Freelance Dietitian and Health Writer. Her specialist areas include gut health and the management of irritable bowel syndrome, including the lowFODMAP diet.

REFERENCES Please visit: nhdmag.com/ references.html

NUTRIENT INTAKE

People with IBS have a poorer quality baseline diet.8 Restricting certain foods and food groups during the FODMAP elimination stage increases the risk

Table 1: Types of FODMAPs (This list shows examples and is not exhaustive) Oligosaccharides: fructans and galacto-oligosaccharides

Wheat, rye, lentils, chickpeas, baked beans, onion, garlic

Disaccharides: lactose

Lactose containing cow’s milk, sheep’s milk, goat’s milk, yoghurt, ice cream, soft cheese

Monosaccharides: excess fructose

Honey, apples, mangos, cherries, pears, watermelon

Polyols

Mushrooms, cauliflower, some artificial sweeteners (sorbitol, mannitol) www.NHDmag.com March 2021 - Issue 161

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COVER STORY of a nutritionally inadequate diet.7 Restricting FODMAPs involves many food groups, including grains, dairy and fruit and vegetables, which could reduce intake of many macro- and micronutrients.9 Studies researching this have found reduced intake of key nutrients, such as carbohydrate, fibre, iron and calcium during the restriction phase of the diet.9 However, one 2019 study showed that when low-FODMAP dietary advice was delivered by a specialist dietitian, intake of most nutrients was not significantly impacted.8 NICE guidelines recommend low-FODMAP advice is only given by suitably qualified professionals,6 such as Registered Dietitians. Key considerations to maintain nutritional adequacy of the restriction phase include: • ensuring appropriate food substitutions and proper reintroduction; • recommending low-FODMAP milk alternatives which are fortified with calcium (and other micronutrients); • ensuring fibre intake is optimised, eg, low-FODMAP fruit, vegetables, oats, wholegrains and fibre supplements; • special care taken in groups who already restrict certain foods, for example vegans, or those at higher risk of nutrient deficiency or malnutrition. DIET DIVERSITY/QUALITY

Exclusion diets, such as the low-FODMAP diet, can become repetitive due to so many restrictions. They may also decrease in quality and diversity, which can negatively impact the diversity of the gut microbiome.10 A 2019 study assessed the quality and diversity of the diet during FODMAP restriction (as instructed by a specialist dietitian) and found that diet quality, but not variety, was significantly reduced versus control diet.8 While the lowFODMAP diet can lead to symptom improvement, the risks of a long-term low-quality diet may lead to other health issues in the future. MICROBIOME

Fermentation of the prebiotic FODMAPs (fructans and galacto-oligosaccharides) by gut bacteria in the large intestine can lead to symptoms in people with IBS. However, this process is also important to feed and grow the gut microbiome.

Studies have shown a negative impact of a low-FODMAP diet on the gut microbiome, such as a significant reduction in faecal bifidobacterial concentrations.11 The significance of this for long-term gut health and symptoms in people with IBS is not known. As dysbiosis is common in IBS, it is concerning that the therapeutic diet could potentially worsen it. In one study, however, the addition of a specific multistrain probiotic ameliorated the negative impact of the low-FODMAP diet on gut flora.12 Other important considerations are the diversity and fibre content of the diet, ensuring FODMAPs are increased to tolerance following the restriction phase, to allow maximal prebiotic fermentation without significant symptoms. COMPLEXITY

The sheer complexity and number of foods that need to be restricted during the low-FODMAP diet (carbohydrates, fruits, vegetables, dairy products and most processed foods) can make it difficult to follow. Patients report it as “demanding”.13 Healthcare professionals must assess the educational level and ability of patients to understand and follow the diet. Stress also plays a key role in IBS via the gut-brain axis (GBA),14 so, following a difficult diet may add to this burden. If necessary, the diet can be simplified for individuals, starting, for example, with single group exclusions such as lactose or wheat, or by cutting key FODMAP foods in the diet and building up as required until symptoms are satisfactory.15 However, these approaches are less well studied and may not provide such significant symptom reductions. DISORDERED EATING

A 2015 systematic review found greater prevalence of eating disorders in people with gastrointestinal disorders (including IBS). When these disorders are controlled by diet, this may be associated with symptoms and anxiety, which may involve the GBA.16 Prior to commencing a low-FODMAP diet, it is good practice to screen for past or present eating disorders, or disordered eating patterns. The dietitian should consider the role of the GBA and food beliefs on IBS symptoms. The lowwww.NHDmag.com March 2021 - Issue 161

COVER STORY FODMAP diet is not intended to lead to weight loss and this may indicate excessive restriction or fear to reintroduce foods. For patients with disordered eating, psychological therapies (discussed below) are more appropriate.7 RESOURCES

The low-FODMAP diet requires commitment in terms of time, food preparation and the additional expense of free-from alternatives.17 This should be assessed and patients should be supported to minimise these difficulties. This can involve providing quick and easy recipes, cheap foods that are naturally low in FODMAPs (eg, potatoes and rice), lists of ‘safe’ preprepared foods (such as the King’s College London Suitable Foods booklet18) and smartphone apps (such as Monash or Food Maestro) that make the diet easier to follow. ALTERNATIVES TO A LOW-FODMAP DIET

Before considering alternative therapies, it is sensible to check whether first-line advice has been implemented and whether lower FODMAP load (without full restriction diet) is appropriate. It is also advisable to review current medications and, in collaboration with a patient’s GP, trial symptom-specific medications such as an antispasmodic for the control of diarrhoea. Other alternative therapies are discussed below. Probiotics Probiotic therapy is an interesting, yet sometimes controversial area of IBS management. A 2018 meta-analysis of 53 studies found that specific multistrain probiotics were effective for managing overall IBS symptoms,19 although more research is needed in this area. Current UK20 and US21 guidelines do not recommend probiotic use for the treatment of IBS due to limitations in the current evidence base. Regardless, probiotics are often desired by patients and considered safe. If trialled, they should be taken for four weeks at manufacturers’ guidelines20 whilst monitoring symptom response.6 Psychological and lifestyle therapies Non-diet therapies can be helpful in the management of IBS symptoms alone or alongside 14

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dietary advice as part of a holistic management plan. NICE guidelines recommend increased activity (if levels are low) and use of regular relaxation techniques.6 Psychological therapies with best efficacy in managing IBS symptoms include cognitive behavioural therapy (CBT) and gut directed hypnotherapy, although others can also provide benefits, such as talking therapies and stress management.22 NICE recommends psychological intervention for those with refractory IBS (no response to diet, lifestyle or medication after 12 months).6 When compared with the low-FODMAP diet in randomised controlled trials, both a 12-week yoga programme and gut-directed hypnotherapy have been found to be equally effective.23,24 These should, therefore, be considered for patients who are unsuitable for or unwilling to input dietary advice to avoid risks discussed here. NHS availability is poor, so patients would usually be required to selffund these options, which can limit their use. Recent advances in technology have made them more accessible, such as free yoga on YouTube and apps that offer gut directed hypnotherapy (such as Nerva). However, these may differ from interventions used in the clinical trials. CONCLUSION

The low-FODMAP diet is an evidence-based dietary approach to IBS management, which is becoming widely used. It should only be delivered by suitably trained Registered Dietitians.25 The diet may not be suitable for all patients and may carry risks. Many of the risks can be mitigated with proper dietetic input and reintroduction of excluded foods. For clients who should not or cannot follow the low-FODMAP diet, non-diet therapies provide good alternative options, providing they are accessible. More research is required into which patient groups best suit different interventions and also combinations of interventions for more holistic treatments (diet plus lifestyle/psychological). A holistic approach encouraging the patient to selfmanage their symptoms is essential to proper long-term symptom control. To end on a quote from Peter Gibson, one of the founders of the diet: “Clinical wisdom is required in utilising the low-FODMAP diet.”7

COVID-19

HISTAMINE INTOLERANCE AND LONG COVID This article outlines recent discussions around histamine intolerance and some long COVID symptoms. Histamine is a chemical that is both made by the body and found in certain foods. It is an inflammatory substance produced by cells during an infection. It encourages an immune response to help fight off infection, thus is important to the human body. HISTAMINE INTOLERANCE

Approximately 1% of the world’s population has a histamine intolerance.1 It arises through an increased availability of histamine in the body and decreased activity of the enzymes that break down histamine. Histamine intolerance can cause symptoms such as diarrhoea, headache, asthma, rhinitis, hypotension, arrhythmia, hives, itching, flushing and other conditions.1 Symptoms can occur after a few hours up to a few days.2 These symptoms are similar to those reported by long COVID sufferers. Anecdotally, some who have tried a low-histamine diet claim it reduces their symptoms. LONG COVID

Long COVID is also referred to as ‘post-COVID syndrome’. It is defined as, ‘symptoms that develop during or following an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis’.3 Recently, scientists have been discussing the role of mast cell activation syndrome (MCAS) in COVID-19.4 Their theory is that long COVID symptoms could be triggered by MCAS, where the mast cells release histamine in response to a viral infection.5 Despite a lack of evidence around histamine intolerance and long COVID, some medical doctors

are now suggesting trialling a lowhistamine diet to see if it improves symptoms.6 DIAGNOSIS OF HISTAMINE INTOLERANCE

To date, there is no reliable test to diagnose histamine intolerance, also known as an adverse reaction to ingested histamine. Diagnosis is usually made through history and a three-step dietary adjustment.7 This would include the use of a food and symptom diary. It has been suggested that the ‘gold standard’ for diagnosing a histamine intolerance is to have a clinical assessment with a medical doctor who is experienced in histamine intolerance (or MCAS). This may include other tests to exclude other conditions. This should be followed by a low-histamine diet for four weeks under the supervision of a Registered Dietitian. It is then recommended that a double-blinded placebo-controlled provocation test is carried out with histamine to establish its effects,1 normally done under medical supervision. However, there is currently no procedure for performing such tests.7

Elaine Anderson RD Elaine is a Freelance and NHS Dietitian with over 12 years of experience in a variety of areas. She has a personal interest in long COVID having had experience of it herself. In addition to her NHS work, Elaine runs Care 4 Nutrition, a workplace health and nutrition consultancy. She can be contacted via email: carefornutrition@ gmail.com or via social media. care_4_nutrition care4nutr care4nutrition

REFERENCES Please visit: nhdmag.com/ references.html

WHAT IS A LOW-HISTAMINE DIET?

A low-histamine diet can be restrictive and time-consuming. Reports from the long COVID community suggest that people have struggled to adhere to it, alongside their debilitating symptoms. In addition, histamine levels in food can have a significant variation and are subject to the age of the food, the storage time and how food has been treated.7 This can cause issues establishing www.NHDmag.com March 2021 - Issue 161

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COVID-19

The low-histamine diet can be extremely limiting and frustrating. The hope is that the diet may not be forever. Table 1: Examples of high-histamine foods1,8,9 High histamine foods Cured, tinned/canned, processed meats such as salami, fermented sausage, fermented ham

Fish such as tuna, sardines, mackerel, herring

Fermented dairy such as aged cheese (Gouda, Camembert, Cheddar, Swiss, Parmesan)

Soured dairy such as buttermilk

Fermented soy products such as miso and soy sauce

Pickled/fermented vegetables such as sauerkraut

Oranges, bananas, tangerines, pineapple, grapes and strawberries

Aubergine, spinach, broad beans

White and red wine vinegar, pickles, dressings containing vinegar, yeast extract

Coffee, cocoa/hot chocolate, green tea

Peanuts

Alcohol Histamine-releasing foods9*

Citrus fruit, strawberries, pineapple

Spinach

Alcohol

Chocolate

Tomatoes and tomato products *It is worth noting that there is still no evidence that histamine-releasing foods have a clinical significance.9

actual histamine content in foods. Table 1 gives examples of foods high in histamine. There are many food lists available on the internet and many have conflicting advice. Some studies report that certain medications and alcohol can inhibit the enzyme diamine oxidase (DAO). This enzyme helps break histamine down in the body. Further research, however, is needed in this area.9 WHY IT IS IMPORTANT TO WORK WITH A DIETITIAN

One of the main reasons for working with a dietitian is to ensure a balanced diet with adequate nutrients is being achieved. The lowhistamine diet can be extremely limiting and frustrating. The hope is that the diet may not be forever. Some individuals may be able to tolerate a certain amount of histamine in their diet after a period of time. Many may also need medications

such as antihistamines or mast cell stabilisers to help manage symptoms, although further research is needed in the area.4 CONCLUSION

Despite the lack of evidence around histamine intolerance and long COVID, healthcare professionals should respect a patient’s decision to trial a low-histamine diet, particularly when other treatments are still lacking. Some may have already tried lowering histamine-containing foods and may well have seen a benefit, but they will need additional support to ensure their diet is adequate. Dietitians can help decrease the possibility of long-term restrictive diets, which can lead to poor health outcomes and a reduced quality of life.7 NB: The information in this article is not a substitute for seeing a medical professional. www.NHDmag.com March 2021 - Issue 161

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CONDITIONS & DISORDERS

MALNUTRITION AND THE GROWING IMPACT OF COVID-19 Malnutrition continues to be a complex global problem with multiple consequences for the individual. This article provides an overview of malnutrition and explores the growing impact of COVID-19. The term ‘malnutrition’ includes both the deficiency and excess of macro- and micronutrients (i.e. energy, protein, vitamins and minerals).1 This can be expanded further to describe two broad common terms: 1 Undernutrition – includes stunting (low height for age), wasting (low weight for height), underweight and micronutrient deficiencies 2 Overweight/obesity – obesity and diet-related noncommunicable diseases such as cardiovascular diseases (heart attack and stroke), some cancers and diabetes2 In the UK, it is estimated that over three million people are affected by undernutrition with 1.3 million over the age of 65 years.3 The term ‘malnutrition’ is often used synonymously with ‘undernutrition’, which will be the focus of this article. The National Institute for Health and Care Excellence (NICE)1 defines malnutrition in terms of undernutrition using the following criteria:

• A BMI of less than 18.5kg/m2 • Unintentional weight loss greater than 10% in the last three to six months • A BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within the past three to six months CONSEQUENCES OF MALNUTRITION

The effects of malnutrition are widely researched and broadly associated with frailty, sarcopenia and poor health outcomes.4 Malnutrition is complex and can affect the function of every organ system in the body.5 Muscle function Loss of muscle and fat due to weight loss can affect mobility with an increasing risk of falls. The muscles of the heart and lungs can also be affected leading to a reduced cough which may delay recovery from respiratory tract infections.

Joanna Injore RD Joanna is an experienced Dietitian who has worked extensively in the NHS. She works at Macmillan Cancer Support and is the owner of JI Nutrition providing private 1:1 nutritional consultations and bespoke services for businesses. www.jinutrition.co.uk ji__nutrition JInjore

REFERENCES Please visit: nhdmag.com/ references.html

Gastrointestinal function Nutrition is needed to preserve the gut function and chronic malnutrition

Figure 1: Malnutrition – a problem of deficiency and excess

Undernutrition

Malnutrition

Overweight/obesity

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References 1. Brown F et al. J Nutr Health Aging 2020; https://doi.org/10.1007/s12603-020-1331-6 [Accessed February 2020] 2. Cawood AL et al. Ageing Res Rev 2012; 11: 278–96. Accurate at time of preparation: February 2021. This information is intended for healthcare professionals only. Fortisip Compact Protein is a Food for Special Medical Purposes for the dietary management of disease related malnutrition 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.

CONDITIONS & DISORDERS Table 1 Risk factors for malnutrition At-risk groups

Social risk factors

Physical risk factors

Adults over 65 years (particularly those in care homes)

Social isolation

Difficulty eating due to poor dentition, poor oral hygiene or illfitting dentures

Adults with long-term conditions, eg, diabetes, renal disease, chronic lung disease3

Poverty

Impaired swallow function or painful swallow due to treatment or disease

Adults with chronic progressive conditions, eg, cancer or dementia3

Anxiety or low mood, which can limit appetite and interest in food

Anosmia (loss of smell) or dysgeusia (taste changes) leading to a reduced appetite

Substance misusers

Limited access to culturally appropriate meals, eg, whilst in hospital or care home

Physical limitations causing difficulty in preparing meals Reduced mobility or access to obtain food Physical side effects of disease or treatments, eg, nausea, vomiting, diarrhoea or pain

can cause changes in villous architecture and intestinal permeability, causing reduction in the colon’s ability to reabsorb water and electrolytes.5 Immunity and wound healing Malnutrition can increase the risk of infection due to reduced cell-mediated immunity and impaired wound healing is well documented.5 Psychosocial effects Malnutrition can result in psychosocial effects such as depression, anxiety, poor body image, altered sleep patterns, isolation and self-neglect. The wider burden of malnutrition in terms of costs to health and social care is significant. Malnourished adults have prolonged hospital stay, present more regularly to their GP and make up 30% of hospital admissions.6 RISK FACTORS FOR MALNUTRITION

Table 1 illustrates the common risk factors for malnutrition divided into three categories: particular at-risk groups, social and physical factors.6 Disease-related malnutrition is multifactorial as a result of the treatment of the disease or the disease itself, which causes the following to occur: 1 Reduced dietary intake 2 Reduced absorption of macro- and or micronutrients

3 Increased dietary requirements due to increased energy expenditure Some of the social and physical factors can also be present, further compounding the risk of malnutrition. Malnutrition, for example, is highly prevalent in older patients with cancer who are undergoing anti-cancer treatments such as chemotherapy. THE IMPACT OF COVID-19

Malnutrition has been an ongoing global issue but, unfortunately, this has been compounded by the emergence of COVID-19. COVID-19 has stimulated a global social, economic and medical crisis and presents a real threat to nutritional status, particularly in the most vulnerable groups such as children and older adults. In January 2021, the UK entered its third lockdown, which, yet again, presents further enforced social isolation. Adults over 65 years of age are already in the at-risk group for malnutrition and for severe effects of COVID-19 with poor prognosis.7 Ongoing guidelines to stay at home will continue to limit this particular group’s access to a wide variety of food creating challenges for individuals to maintain a healthy diet.8 The impact of ongoing social isolation is likely to induce negative emotions such as stress, sadness www.NHDmag.com March 2021 - Issue 161

CONDITIONS & DISORDERS Figure 2: Food Insecurity and Experience Scale from The Food and Agriculture Organisation of the United Nations9

and distress, all known to be associated with reduced motivation or desire to eat,6 further compounding the risk of malnutrition. Limited regular contact with friends or family may also mean that possible signs and symptoms of malnutrition, such as weight loss, loss of appetite and fatigue, may go unnoticed. The economic effect of COVID-19 has been hard hitting, with a surge in redundancies and an increasing rate of unemployment posing a real threat of food insecurity. Food insecurity is a ‘limited access to food due to lack of money or other resources’.9 The level of food insecurity can be measured by the Food Insecurity and Experience Scale (FIES) which ranges from worrying about obtaining food to experiencing hunger (see Figure 2). A recent study10 has illustrated that COVID-19 has exacerbated food insecurity for vulnerable groups such as the unemployed, adults with disabilities, families with children and members of the black, Asian and other minority ethnic groups (BAME).10 These groups are not only experiencing food insecurity due to

limited income, but also due to environmental factors such as poor availability in the shops or being unable to go out due to self-isolation.10 The COVID-19 virus has appeared to disproportionately affect low income and ethnic minority groups, which, along with the greater risk of malnutrition, may be contributing factors to poorer outcomes and severe disease.11 SUMMARY

Malnutrition continues to be a huge global problem and, with the ongoing impact of COVID-19, is likely to affect more of the population. The risk of malnutrition is already complex and multifactorial without COVID-19, but the pandemic has created new problems of food insecurity for those already vulnerable to health inequalities. So now more than ever it is vital that we identify those at risk of malnutrition. Malnutrition should continue to be a consideration for all healthcare professionals and usual practice should be adapted to allow screening to take place remotely or by patients or carers themselves.

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CLINICAL

ADULT TUBE FEEDING THEN, NOW AND IN THE FUTURE Ever wondered what were the beginnings of enteral tube feeding? How did it emerge? What were tubes made of? How was nutritional formula made? This article presents the development of adult tube feeding throughout history. The earliest description of tube feeding was found on 3500-year-old papyrus, although it was not tube feeding as we know it. Due to issues with accessing the upper gastrointestinal tract, ancient Egyptians and Greeks, including Hippocrates, are reported to have performed rectal feeding. From then on, rectal alimentation was commonly used throughout history. Although nasogastric feeding was introduced in the 16th century, rectal feeding still gained popularity in the 19th century.1-3

Currently, in some wellness companies, the rectal route is used to provide colonic irrigation, also known as hydrotherapy. Its purpose? To flush waste materials out of the body using water, in order to ‘cleanse’ yourself. However, according to the NHS, there is no scientific evidence to suggest any health benefits of hydrotherapy, and the list of side effects remains extensive from irritation and dehydration to infection and bowel puncture.4

FOOD ENEMAS

The humble beginnings of nasogastric feeding date back to the 16th century, when nasogastric tubes were made out of silver or leather. An animal bladder served as an equivalent of the 20th century ‘formula bottle’. The 18th century brought major advances when John Hunter used a catheter and syringe approach to deliver nasogastric feeding. Later, investment in device developments led to inventions including a tube made of spiral wire covered with gut and another consisting of an eel skin drawn over flexible whalebone for orogastric feeding. However, these tubes were very large in diameter, not flexible and difficult to insert.1,3,5,7,8 The early 19th century brought major advances in psychiatry, with tubes being widely used for forcibly feeding patients with mental health issues. It wasn’t until the late 19th century when medics started using softer rubber tubing. Only then did tube feeding stop being an extremely traumatic experience for patients.3,5,7,8

In 1878, food enemas pushed into the rectum twice daily with a wooden syringe were claimed to provide an adequate provision of fluids and nutrients. One of the most famous reports of rectal alimentation was following President Garfield’s gunshot wound. For 79 days, every four hours he was rectally infused with peptonised beef broth, several drops of opium and whisky!1-3 Until 1940, the rectal route was still used to provide water, saline and glucose solutions. In 1941, it was a recommended form of nutrition in US military hospitals and infamously used as a method of torture by the Central Intelligence Agency (CIA). Solutions contained a combination of wheat or barley broth, milk, eggs, wine, brandy, tobacco and meat mixed with wax and starch. Defibrinated blood was also considered for that purpose but dismissed after reports of causing rectal irritation.1-3

Bogna Nicinska RD 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.

NASOGASTRIC BEGINNINGS

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REFERENCES Please visit: nhdmag.com/ references.html

CLINICAL

The stomach pump became the first form of gastric feeding.

GASTRIC FEEDING TECHNIQUES

The stomach pump became the first form of gastric feeding. Liquid formulas comprised mixtures of jellies, eggs, milk, wine, beef tea, water with sugar beaten in, thick custards, mashed potatoes and predigested milk treated with acid or enzymes (brandy or whisky).5-7 In 1837, the purpose of potential gastrostomies was being raised. The procedure itself came to life eight years later; however, due to many associated infections, physicians were more inclined to sway towards the use of nasogastric tubes. That took a turn in the 1860s with Lister’s introduction of an aseptic surgical technique.3 The 20th century was the most fruitful in tube feeding developments. It brought the invention of a minimally invasive endoscopic method of placing percutaneous endoscopic gastrostomy (PEG). Studies of the benefits of early postoperative feeding were being published. In one of them, Polish-American gastroenterologist, Max Einhorn, stated that the rectum and colon are simply organs to absorb remaining fluids and for excreting faeces. The main focus then evolved around the duodenum, which was considered an organ that secreted digestive juices of great importance. Einhorn introduced small bowel feeding in 1910 using a rubber tube. Soon after, other physicians followed in his footsteps. That led to further developments, including the invention of the nasojejunal tube and a gastrojejunal dual lumen tube. Physicians experimented with surgical placement of jejunal tubes and nutritional formulas. Used solutions consisted of 200ml 26

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of milk, 15g of dextrose and 8ml of whisky at two-hour intervals. For patients who did not tolerate bolus feeding, continuous feeding was introduced.1,3,5 BLENDED DIETS

Medical science advances led to a greater understanding of the absorption of nutrients and biochemistry of water-soluble vitamins. As we started discovering more about diseases, we also started developing more diets for certain conditions.5 For tube feeding, blended diets were more commonly used (infant foods + hospital food) to mimic the natural experience of eating. Enterally-fed formulas started being commercially available in the 1950s. Our understanding of human amino acid requirements contributed to the development of ‘space diets’ for astronauts, which were based on essential amino acids, glucose, vitamins and minerals. They maintained nitrogen balance while ensuring minimal faecal output. Although astronauts rejected ‘the elemental diets’ due to their strong and bitter taste, they did not go to waste. They found application in the local hospital, to tube-fed patients with gastrointestinal disorders. This was the beginning of elemental diets.1,2,3,5 CURRENTLY . . .

Relentless technological advancements in the enteral feeding market translated into improvement of feeding devices and nutritional formulas. There are now multiple factors considered in tube development. The most important one is the biocompatibility, which encompasses:

CLINICAL

A collection of 19th century enema apparatus and syringes.

• the body’s response to the material (inflammation, allergic reaction); • the material’s response to the body: – leaking due to gastric acid or feeding formulas, – swelling (due to medication, alcohol); • the body’s response to the material’s response (degradation might cause a release of small particles causing the body’s response).2, 5,8 We can already ensure patient-friendly portable pumps and tubes made from extensively tested materials to prevent cracking in highstress applications. Most pumps include a screen, multiple programming settings and several alarm options, eg, a pressure alarm. You can choose the preferred language, program flushing intervals, check the history of previous feed rates and program lock-out features to prevent manipulation. Tubes are smaller in diameter and made from softer polymers.5,9 WHAT DOES THE FUTURE HOLD?

The rising adoption of enteral feeding has resulted in an increase in uptake of enteral feeding tubes across the globe. The enteral feeding devices market is projected to increase from USD 3.2 billion to USD 4.4 billion by 2025.9,10 In developing countries across the Asia Pacific, Latin America and the Middle East, reimbursements are insufficient. This poses a significant challenge to the widespread adoption of enteral feeding. This is now important more than ever. Why? Because these are expected to be the fastest-growing regional markets. There is an increasing incidence of preterm births

in the Asia Pacific, and older populations are increasing in number worldwide. Along with cancer being one of the most prevalent diseases in developing countries (India, China, Brazil), this means that demand for enteral feeding devices in these countries is expected to grow. In a nutshell: insufficient reimbursements, rapidly increasing demand and the unforeseen toll of the COVID-19 pandemic.9,10 In developed countries such as the US, Canada, Germany, France, the UK and Japan, enteral nutrition therapy is reimbursed (by insurers, governments, national health insurance, etc). Constantly changing requirements of healthcare providers, patients’ growing preference for low-profile tubes and a shift of healthcare provision from hospitals to community settings, are expected to propel the growth of the enteral feeding pumps market.9 CONCLUSION

Based on archaeological findings and documentation, we can assume that, throughout history, people have always known that nutrition is essential for humans to thrive. Currently, we can observe a growing awareness of enteral nutrition due to an increasing number of preterm births, a rising geriatric population and rising incidents of cancers, all factors that are driving the growth of the enteral feeding healthcare market. We can only speculate on what the future holds, but ongoing scientific investigations will likely lead to developing more sophisticated treatment techniques, with simultaneous improvement in quality of life for patients.1,9,10 www.NHDmag.com March 2021 - Issue 161

CLINICAL

NASOGASTRIC FEEDING AND THE EATING DISORDERS PATIENT

Oana Oancea,RD Oana works with Day Centre patients and outpatients. She also holds discussions about healthy eating and mental health at the Carers Support Centre in Dumfries. In the past, she led the CAMHS Addiction and Eating Disorder Unit in Priory Hospital, Chelmsford.

REFERENCES Please visit: nhdmag.com/ references.html

Nasogastric feeding to support life in eating disorder patients is a last resort. This article considers the protocols involved and outlines a moving case study. Specialised nutrition support, particularly enteral feeding, has been used for centuries. Feeding solutions, devices and placement techniques have evolved over the years.1 One such example in recent history was the force-feeding of suffragettes who went on hunger strike whilst in prison. The Government took action by forcibly feeding them, arguing that this “ordinary hospital treatment” was necessary to preserve the women’s lives.2 Forcible feeding as carried out on the hunger strikers was a brutal, lifethreatening and degrading procedure, undertaken by male doctors on struggling female bodies.3 Mary Leigh, a well-known suffragette, described her experience of the feeding in a muchcirculated pamphlet at the time: “The sensation is most painful – the drums of the ear seem to be bursting, a horrible pain in the throat and the breast. The tube is pushed down 20 inches… I resist and am overcome by weight of numbers.”4 Lady Constance Lytton wrote: “My jaws were fastened wide apart, far more than they could go naturally... Then the food was poured in quickly; it made me sick a few seconds after it was down and the action of the sickness made my body and legs double up, but the wardresses instantly pressed back my head and the doctor leant on my knees.”5 As a result of public disapproval, the Government ended force-feeding

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with the Cat and Mouse Act of 1913, which released prisoners once they were weakened by hunger.6 Today we have clear guidelines and protocols. We use nasogastric feeding (NG) as a last resort to save a life, no longer to punish. Most published guidelines regarding nutrition support for the critically ill recommend the use of enteral nutrition (EN) rather than parenteral nutrition (PN), according to an accumulating body of evidence that suggests EN is associated with better clinical outcomes than PN.7 CONDITIONS TO INITIATE NG IN THE EATING DISORDER PATIENT

Feeding purposes NICE guidelines state that NG tubes should only be used in people who are malnourished or at risk of malnutrition and: • the patient is less than or equal to 85% ideal body weight (IBW); • the patient has experienced greater than one month severe restriction (less than 500 calories per day) prior to admission; • a three-day calorie count reveals intake below maintenance/gain calories; • the patient is severely restricting fluid intake and needs the NG tube to maintain hydration status. Medication delivery • to deliver certain medications directly into the stomach of patients with the same stipulations as feeding.

CLINICAL

Today we have clear guidelines and protocols. We use nasogastric feeding (NG) as a last resort to save a life, no longer to punish.

Table 1: Contraindications of tube feeding Absolute contraindications

Relative contraindications

Complications of NG placement

Mid-face trauma

Coagulation abnormalities

Gagging or vomiting

Recent nasal surgery

Recent alkaline ingestion (due to risk of oesophageal rupture)

Tissue trauma along the nasal, oropharyngeal or upper gastrointestinal tract

Oesophageal varices (untreated or recently banded/cauterised)

Oesophageal perforation (rare)

Oesophageal strictures

WHEN IS TUBE FEEDING COUNTERPRODUCTIVE OR CONTRAINDICATED?

Tube feeding is not recommended in the following circumstances: 1 When there is an anatomical abnormality of the nose. 2 When a patient has anorexia and binge-purges, and the patient may be hypokalemic. 3 When the patient has refeeding syndrome or electrolyte disturbance needs to be corrected before the patient is aggressively refed. 4 When a patient inflicts self-injury that could be a limiting factor in considering an NG tube. 5 When the patient has a “need” to be sick and the NG tube can become a personal statement.

See Table 1 for contraindications. THE MENTAL HEALTH ACT

The Code of Practice states that: ‘Any restrictions should be the minimum necessary to safely provide the care or treatment required having regard to whether the purpose for the restriction can be achieved in a way that is less restrictive of the person’s rights and freedom of action.’ Patients who receive an NG feed under restraint often describe the experience as being traumatic, especially for patients who were victims of physical abuse, which has an impact on establishing or maintaining a therapeutic and trusted relationship with staff members. The deterioration of the relationship between patient and healthcare professional can be due to the lack of support after a restraint. During restraint, patients experience a range of emotions, www.NHDmag.com March 2021 - Issue 161

CLINICAL Figure 1: NG tube position on X-Ray

including confusion, frustration, worry, a sense of isolation and powerlessness. The restraint comes with a high risk of emotional damage and can lead to negative consequences on wellbeing. Social determinants are sometimes a factor related to admission and include psychosocial stressors, occupational and social backgrounds and histories of being survivors of abuse. The treatment from ED staff and the use of restraints has a range of effects on patients, including scepticism and distrust of the medical system, the worsening of existing psychiatric conditions, or healthcare avoidance.8 The therapeutic relationship with ED patients can be fractured due to coercion and physical restraint and this can impact the relationship with food. Before any restraint, we need to be absolutely certain that we did everything in our power to avoid this. We need to be 100% certain that we tried all the possibilities before proceeding with an NG feed under restraint. Without solid and ongoing psychological support, patients may begin a spiral of negative emotions with subsequent ED visits and instinctively escalating short-term agitation and aggression as a protective shield based on prior experiences. Any decision that leads to the use of physical restraint as a last resort should be thoroughly thought through, balanced and well evidenced. It can be very 30

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helpful to reduce the number of feeds given over a 24-hour period to minimise the trauma caused and reduce the high levels of anxiety experienced by patients. A lower number of feeds allows patients to focus and use the time in a beneficial way to improve their wellbeing. We need to encourage patients to come out from their bedrooms and to engage positively in activities unrelated to their ED. It is also beneficial for the patient to receive psychological support between feeds. Reducing the number of feeds conflicts with general practice, i.e. that feeds should be given after each meal and snack to promote normal eating patterns. Every healthcare professional has their own way to approach and assess the problem and every patient is different. Personally, I like to decide with the patient when it’s the right time to focus on normal eating patterns and discuss in advance the steps to achieve this. One of our main objectives is to work with the patient towards acceptance of feeding without physical intervention during these periods. Supervision and support of staff, as well as debriefing and motivational enhancement work with patients, are essential. We need to make clear to the patient at every opportunity that we work with them, not against them. Many of our patients identify very easily with the illness, so trying to externalise the ED is very useful.

CLINICAL CASE STUDY LK is a 27-year-old woman who, over many years, has suffered from anorexia nervosa. She was first diagnosed when she was a teenager at 15 and now has a formal diagnosis of a Severe and Enduring Eating Disorder (SEED). The healthcare professionals who are treating her recognise that her illness is chronic and severe. LK is at serious risk of death because her weight is so low (26kg). She could die at any time from cardiac arrest. She also suffers from a number of different presenting conditions as a result of severe and chronic malnutrition. These include osteoporosis, oedema (painfully swollen legs), anaemia (low blood count leading to extreme fatigue and tiredness) and unstable blood salts (the result of low potassium levels which expose her to possible heart complications and the risk of a cardiac arrest as well as adding to her debilitating fatigue). The only form of life-sustaining treatment now available to her is in the form of tube feeding using physical restraint or chemical sedation. The NHS Trust and the team of treating clinicians who have been responsible for providing care for LK now apply to the court for declaratory relief pursuant to sections 4 and 15 of the Mental Capacity Act 2005 in these terms: i) It is in LK’s best interests not to receive any further active treatment for anorexia nervosa. ii) LK lacks capacity to make decisions about treatment relating to anorexia nervosa and there is only one treatment option available to LK given the significant deterioration in her health and that is to undergo forced nasogastric feeding through the insertion into her stomach of a tube through which liquid nutrients can be delivered. LK leads her life one day at a time and she makes the most of each day knowing that one day she may simply not wake up. Whilst much of her waking day is spent engaging with her treating team both as an outpatient and within the community, there are still activities that bring her much pleasure on a day-to-day basis. She places enormous value on the time she spends with her parents, even when they are doing simple activities such as watching favourite television programmes together. She has a number of pets with whom she continues to engage. Court decision The following is an extract from the court decision relating to the application by LK’s clinical team. It reads as a moving conclusion to this case study: “I would want LK to know that I have considered all that has been said on her behalf very carefully. I have read, and re-read, all that she has said to me through the two very personal statements which she has prepared. No one who heard (or reads in this judgment) her account of her experience of tube feeding could fail to be both moved and appalled by its graphic detail. I recognise fully the effects upon her of that experience. I understand completely why, even in the context of a life-critical decision, she does not wish to endure further treatment. I accept that she is aware of the options which are currently available to her and the likelihood that tube feeding is very unlikely now to produce any sustainable benefits. I acknowledge that she understands the risks of any attempt to restart tube feeding. In this context she has shown remarkable dignity in her contemplation of a very significantly shortened life expectancy. Despite all she has endured in the past 15 years (which is the majority of her life), there is still much which makes her life worthwhile. She has the love of a devoted family and it is abundantly clear to me from all the material I have read that the unstinting love and support they have provided over the years has been a very precious resource to this young woman in coping with all she has had to endure. “The issue at the heart of this case is the ability of this particular illness in its current presentation in LK’s case to so infect to such a significant extent the very nature of her decision-making processes which are engaged in relation to food, calories and weight gain that any decisions flowing from those processes cannot be considered as legally capacitous decisions. This is not to introduce any generalisations or circularity of argument into the decision which is now before the court. I am concerned only with LK, the powerful evidence which she has presented to the court, and the professional views of those charged with the responsibility of caring for her. I have weighed fully in the balance the fact that she is intelligent, articulate and demonstrates clear insight into some of the aspects of her illness. She is also a delightful young woman despite all that she has gone through. That she has managed to retain personal and emotional resilience to the extent she has is humbling to any reader of the chronology of interventions she has endured in the attempts of professionals to reverse the progress of her illness.”

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CONDITIONS & DISORDERS

TYPE 1 DIABETES AND INTUITIVE EATING Few studies are available that look at the effects of intuitive eating (IE) on Type 1 diabetes (T1D) management. This article considers the research available on both, demonstrating how traditional T1D management can lead to disordered eating behaviours, and examines how IE could provide a complimentary management option for T1D. T1D is an autoimmune disorder characterised by insulin dependence. Its onset most often occurs in youth and represents about 8% of diabetics in the UK.1 It is typically caused by an unknown trigger, which activates the immune system and leads to the destruction of the insulin-producing beta cells in the pancreas. Insulin is an essential hormone that allows glucose to enter the cells, therefore reducing blood glucose. Insulin can also store excess glucose as glycogen and fat in the liver and adipose tissue, respectively. Without insulin, glucose cannot be taken up by the tissues and remains in the blood, causing high blood glucose (hyperglycaemia), which can lead to a series of health conditions, such as retinopathy, neuropathy and nephropathy. The opposite trend – hypoglycaemia – occurs when there is too much insulin, causing more glucose to enter the cells than needed, severely lowering blood glucose. Hypoglycaemia (hypo, or ‘a low’) is dangerous; it starts with dizziness and fatigue, and if untreated, can lead to convulsions and potentially death. However, this is extremely rare.2 Maintaining blood glucose in the target range is, therefore, essential. Glycaemic status is measured using HbA1c, a marker that determines the amount of glycated red blood cells over three months. Excess glucose attaches to red blood cells during hyperglycaemia, thereby glycating them. The ideal

Eloize Kazmiersky ANut

HbA1c range for an individual with T1D is between 6.5% and 7.5%2 (4858mmol/mol).3 INSULIN ADMINISTRATION

Insulin administration is essential for anyone with T1D. The two main ways of delivering this medication are multiple daily injections (MDI) and the insulin pump. MDI consists of using two different kinds of insulin: 1 a background or long-acting insulin, which releases insulin continually in tiny doses for 8-24 hours depending on the brand; and 2 fast-acting insulin, which acts within 15 minutes to one hour of injecting. Patients with T1D on MDI focus on matching the number of carbohydrates eaten to the correct insulin dose, thanks to ratios previously established by the patient’s endocrinologist.4 This is required as carbohydrate-rich foods get digested into glucose, thereby raising blood glucose. The insulin pump is a small device, which can be tubular or not. Tubular pumps are connected to the body via a tube linked to a catheter and a small infusion kit with a cannula that sits under the skin. Non-tubular pumps often communicate with the catheter via Bluetooth or through a smartphone, or another specialised device, creating a closed-loop system. Fast-acting insulin

Eloize graduated from the University of Nottingham in June 2020 with a BSc in Nutrition. She is further undertaking an MSc in Dietetics at Ulster University, in order to specialise in eating disorders and the psychology behind eating behaviours. eloize_nutritional_ baker EKazmiersky

REFERENCES Please visit: nhdmag.com/ references.html

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CONDITIONS & DISORDERS

Using diet, exercise and lifestyle to reduce the number of insulin injections needed is one strategy for T1D management. is injected permanently and continuously with both methods. Some pumps automatically calculate the amount of insulin per amount of carbohydrates ingested, based on the preprogrammed ratios. Some individuals prefer this option to MDI, as it allows more freedom from calculations, injections and overall better control, with HbA1c reduced by 0.9% after six years follow-up.5 However, pumps require significantly more equipment, can break down, can be expensive and cannulas can get infected.5,6 TRADITIONAL DIETARY MANAGEMENT

Using diet, exercise and lifestyle to reduce the number of insulin injections needed is one strategy for T1D management. The most popular diets adopted by some to help manage T1D are the low-carb and ketogenic diets. These were initially the only way to treat T1D before insulin was discovered, and little to no carbs consumed significantly reduces insulin injections. Although research in this area is limited, several studies have concluded that low-carb and ketogenic diets improve overall glycaemic control in T1D treatment short-term. A ketogenic diet was also 34

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associated with more hypoglycaemic events and dyslipidaemia.7 The very nature of T1D treatment can potentially trigger eating disorders (EDs) or disordered eating behaviours. Up to 60% of one sample8 qualified for the diagnosis of a diabetes-specific ED, diabulimia. Young girls with T1D are 2.6 times more likely to suffer from an ED than the general population.9 Some reasons offered for these alarming statistics include: • fear of hypoglycaemic events10 – low blood glucose symptoms are unpleasant and potentially debilitating, getting in the way of everyday life; • overtreating low blood glucose – eating or drinking too much to treat hypoglycaemia can spike blood glucose, requiring ‘unnecessary’ insulin to return to the target range, which can lead to weight gain;11 • increased anxiety and depression symptoms caused by T1D;12 • significant focus on eating and weight, as well as potential dietary restriction, leading to binge eating and insulin restriction;12

CONDITIONS & DISORDERS • body image and self-esteem issues – women with T1D are on average 6.8kg heavier than non-diabetic women, potentially leading to these issues.13 WHAT IS INTUITIVE EATING (IE)?

There is no one set definition for IE. Generally, it can be considered a group of principles that encourage reconnecting with hunger and fullness bodily cues and letting go of any diet culture, weight shaming/stigma and food rules.14 IE is often used as a tool for people who suffer from disordered eating to prevent them from spiralling further and developing an ED, one of the most fatal psychiatric diseases.15 Treating an ED requires special attention from a team of specific healthcare professionals. IE is not sufficient as a treatment alone for an ED, but can serve as a toolbox for people with disordered eating behaviours.16 The research The peer-reviewed and only study currently available exploring the impact of IE on T1D management suggests that IE could be beneficial to adolescents with T1D to reduce emotional eating and improve overall glycaemic control by preventing an increase in HbA1c. It showed that adolescents with T1D have slightly lower IE scores (according to the IE scale) than controls. A higher frequency of blood glucose selfmonitoring was significantly associated with lower reliance on internal hunger and satiety cues. The study also focused on emotional eating: glycaemic control was worse in those engaged in these behaviours. However, IE was associated with lower HbA1c: for each unit increase of the IE score, HbA1c was significantly lower by 22%.16 HbA1c was also lower in those who selfmonitored blood glucose levels more frequently. These findings echo the results of similar studies done on people with Type 2 diabetes. In

conclusion, the study16 demonstrated that T1D and its management are associated with less reliance on internal cues of hunger and satiety and that emotional eating can harm T1D control. However, IE has a significantly beneficial impact on emotional eating and HbA1c levels.16 MY PERSONAL EXPERIENCE

I have found that IE has helped me progress tremendously in my T1D management. The principles behind IE not only improved my relationship with food but with my chronic illness as well. It removed the guilt I felt for wanting to eat more and hence needing to inject more. When I was doing the Dose Adjustment for Normal Eating (DAFNE) course, I was constantly comparing myself to my peers, and it made me realise that I am a lot more insulin resistant than most people with T1D. Initially, I felt self-conscious about it, but IE principles helped me accept myself and listen to my body’s needs and cues, albeit from a nutritional or diabetes standpoint. Sometimes I can feel that I am going low, so I will have a small snack to start feeling better again (despite my doctors not liking that). Alternatively, I can feel when my blood sugar is spiking, which pushes me to check my levels and treat accordingly. IE has helped me ‘dedramatise’ T1D and has taken away a lot of the guilt I felt in the past for the way I ate and its impact on my levels. CONCLUSION

Research into the area of IE as a dietary management option for T1D is nascent. It requires far more investigation to establish a causal link of the potential benefits of IE on T1D management. More observational and intervention studies on a larger population scale and environment are needed, the results of which could provide people with T1D to simultaneously improve their glycaemic control and relationship with food using IE methods.

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PAEDIATRIC

PAEDIATRIC ALLERGIES AND WEANING Introducing solid foods can be a worrying time for parents, especially if a baby suffers from an allergy. Some parents with perfectly healthy infants may simply be concerned about high profile allergens such as peanuts and eggs. This article looks at the main food allergens and discusses the recommendations and advice for safe and successful weaning. In the UK, 7.1% of breastfed children have increased prevalence for food allergy: 1 in 40 develop a peanut allergy and 1 in 20 develop an egg allergy.1 Children who have early onset eczema are at an even higher risk of developing a food allergy, particularly peanut allergy.2 Increasing numbers of children admitted to hospital for anaphylaxis reflects the increase in prevalence of food allergy in children in the UK.3 In the past decade the guidance and advice around when to introduce allergens into an infant’s diet has changed and is varied, causing healthcare professionals and parents confusion. Fortunately, over the past five

Roslyn Gray RD

years there has been increasing research into food allergies and weaning, which focus on the prevention of food allergies, such as the LEAP and EAT studies, with data from both showing that introducing allergenic foods at the same time as other solid foods may in fact protect infants from developing a food allergy.4 WHAT ARE THE MAIN ALLERGENS?

Roslyn is a Registered Freelance Dietitian specialising in paediatrics and eating disorders. www.graynutritionrd.co.uk graynutritionrd

REFERENCES Please visit: nhdmag.com/ references.html

There are 14 main allergens that are the most likely to trigger an allergic reaction in the UK population (see Table 1). By law, these allergens have to be highlighted on an ingredients list on any prepackaged foods you buy.5

Table 1: Main food allergens (UK) Cow’s milk

Shellfish (not to be served raw or lightly cooked for infants)

Egg (egg without the red lion stamp should not be eaten raw or be lightly cooked for infants)

Fish

Cereals containing gluten, including wheat, rye, barley and oats

Mustard

Tree nuts (crushed, ground or in a butter for children under five years)

Celery

Peanut (crushed, ground or in a butter for children under five years)

Sulphur dioxide

Sesame

Lupin

Soya

Molluscs (not to be served raw or lightly cooked for infants) www.NHDmag.com March 2021 - Issue 161

WW’SGY E NOR CAOLLER

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Help them face life’s adventures EleCare® is designed to help support the immune needs of formula-fed infants with severe cow’s milk allergy and/or multiple food allergies.

EleCare is the ﬁrst amino acid-based formula to contain 2’-FL*†, a major component of most mothers’ breast milk:1 Helps support the immune system in the gut and beyond 1–3 Contains 2’-FL* which has proven benefits on the gut and systemic immune responses‡

Supports healthy growth and symptom resolution§4–7 Trusted by mums and healthcare professionals8,9

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Contact your local Abbott Account Manager to learn more or call Freephone Nutrition Helpline on 0800 252 882 IMPORTANT NOTICE: Breastfeeding is best for infants and is recommended for as long as possible during infancy. EleCare is a food for special medical purposes and should only be used under the recommendation or guidance of a healthcare professional. *The 2’-FL (2’-fucosyllactose) used in this formula is biosynthesised and structurally identical to the human milk oligosaccharide (HMO) 2’-FL, found in most mothers’ breast milk.1 †MIMS. September 2020. ‡Studies conducted in healthy-term infants consuming standard Similac formula with 2’-FL (not EleCare), compared to control formula without 2’-FL. §Studies conducted in infants fed standard EleCare formula without 2’-FL. References. 1. Reverri EJ, et al. Nutrients. 2018;10(10). pii: E1346. 2. Goehring KC, et al. J Nutr. 2016;146(12):2559–2566. 3. Marriage BJ, et al. J Pediatr Gastroenterol Nutr. 2015;61(6):649–658. 4. Borschel MW, et al. Clin Pediatr (Phila). 2013;52(10):910–917. 5. Borschel MW, et al. BMC Pediatr. 2014;14:136. 6. Sicherer SH, et al. J Pediatr. 2001;138:688–693. 7. Borschel MW, et al. SAGE Open Med. 2014;2:2050312114551857. 8. RTI research. Abbott EleCare No.1 Dr Recommended. Final Results. 2019. 9. Abbott. EleCare Promotional Claims Parent Survey. 2019. UK--2000065 September 2020

PAEDIATRIC Table 2: Recommendations for introducing food allergens9 Allergen

Recommendations

Egg

Choose British Lion stamped eggs. Egg in raw form is more likely to cause an allergic reaction than in a baked food. Boiled egg could firstly be offered mashed into other cooked foods, eg, vegetables or rice. Aim for one egg over the course of the week.

Peanut

Never give whole peanuts or chopped nuts. Use finely grounded nuts or a smooth peanut butter, or ‘puffed peanut’ snacks.

Tree nuts

Never give whole nuts or chopped nuts. Use finely grounded nuts or smooth nut butters, eg, cashew butter, almond butter mixed with yoghurt, porridge or fruit.

Cow’s milk

Sugar-free yoghurts or fromage frais, fresh whole milk added to meals, eg, porridge, sauces, mashed potatoes.

Wheat

Weetabix or other cereals containing wheat, well-cooked pasta, toast fingers.

Seeds

Hummus mixed with tahini (sesame seeds), crushed seeds added to yoghurt, porridge or fruit.

Fish, seafood

Pureed, flaked or mashed cooked fish (cooked haddock, salmon or trout), or seafood (prawns, crab, mussels).

Soya

Soya is found in many bread products and so does not need to be offered separately as a soya product.

DIETETIC ADVICE AND RECOMMENDATIONS

For the general population, the UK Department of Health recommends exclusive breastfeeding for around the first six months of life and the introduction of solids from around six months of age alongside breastfeeding.6 Recommendations include the following: • Babies with a known risk factor for food allergy should be introduced to cooked egg and then peanut alongside other solids early in the weaning process, when they are developmentally ready.7 • Babies with no risk factors for food allergy should be introduced to solids at around six months of age. Cooked egg and peanut should be included with other foods that are eaten as part of their family’s normal diet.8 • The deliberate exclusion or delayed introduction of specific allergenic foods may increase the risk of developing a food allergy to the same foods.9 FIRST STEPS INTO SOLID FOODS

There are three main considerations: 1 Can baby hold their head up and sit unsupported? 2 Does the baby have hand-eye coordination? Do they bring food to their mouth? 3 Can they move food from the front of their mouth to the back of their mouth and swallow?

Once the infant is ready to wean, at around six months of age, parents/carers can introduce complementary foods. They should start by offering small amounts of vegetables, fruit, starchy foods and protein. Once they feel confident that baby is managing purees, they should start to consider introducing allergens with the following considerations: • Ensure baby is well and not recovering from any sickness. • Include foods associated with food allergies that are part of the family’s diet. These can include egg, foods containing peanut and tree nuts, pasteurised dairy foods, fish/ seafood and wheat. • Introduce one allergen at a time. • Consider offering food earlier in the day, for example at breakfast or lunch, to allow for time to monitor any signs or reaction. • Start with a small amount, eg, quarter teaspoons and slowly increase the amount over the next two to three days. • Once foods containing allergens have been introduced, it is important for parents to continue introducing those foods, particularly egg and peanut, aiming for two to three times a week. • If the infant does have eczema, it is best to make sure their skin is in a good condition prior to introducing a new allergen. www.NHDmag.com March 2021 - Issue 161

PAEDIATRIC Table 3: Symptoms of immediate- and delayed-type food allergies9 Immediate-type food allergy

Delayed-type food allergy

Symptoms are caused by IgE antibodies and usually occur within 30 minutes of eating the triggering food.

Symptoms usually happen hours to days later, and: • recur when the food is eaten again • resolve when that food is avoided

Mild-moderate allergic symptoms include: • swollen lips, face or eyes • itchy skin rash, eg, hives • abdominal pain, vomiting Severe symptoms (anaphylaxis) include: AIRWAY: BREATHING: CONSCIOUSNESS: • persistent cough, swollen tongue, hoarse cry • difficult/noisy breathing, wheezing • pale or floppy • unresponsive/unconscious

Gut symptoms include: • recurrent abdominal pain • worsening vomiting/reflux • feeding difficulties • loose/frequent stools (>6-8 times per day) or constipation/infrequent stools (2 or fewer per week) Skin symptoms include: • skin reddening • itching • worsening of eczema Delayed-type food allergy is of particular concern when the baby’s growth is also affected. Delayedtype allergy is not caused by IgE antibodies, and cannot cause anaphylaxis.

• If the infant dislikes the food, reassure parents to be patient and try again another day. • Keep a food diary of what foods have been introduced and any reactions that occur. DIETETIC MANAGEMENT OF A SUSPECTED FOOD ALLERGY

Firstly, it is important to distinguish between a food intolerance and an allergy and to define what an immediate-type food allergy reaction is compared with a delayed-type food allergy. Part of the dietetic assessment is taking a detailed allergy-focused history concentrating on: • parents’ diet recall and suspected allergens; • family history of atopic disease and allergies; • symptom history: age at onset of symptoms, rate of onset, spread and severity of symptoms, as well as the frequency of symptoms; • any current food exclusions or past food exclusions that have been tried previously. WHAT ABOUT INFANTS AT HIGHER RISK OF FOOD ALLERGY?

Some infants are at a higher risk of developing a food allergy, including those:

• with eczema; • who already have a food allergy; research has shown that these infants may benefit from the introduction of foods containing egg and peanut from four months alongside other complementary foods;10 • who have known allergies – parents should not continue to feed their baby something they are reacting to. Referral to a specialist allergy clinic is recommended for all infants with immediate-type food allergy. WHAT ABOUT OTHER SIBLINGS?

Often if an older sibling has a food allergy, parents are concerned that their younger children may also have it. Recent studies have found that this factor alone does not significantly increase the risk of food allergy in an infant sibling.11 However, parents may delay that particular allergen from being introduced, which, thereby, increases the risk. Of course, if members of the household do have food allergies, parents need to carefully plan introductions of that allergen without putting their other children at risk of an allergic reaction.

COMMUNITY

NUTRITION AND HYDRATION IN THE ELDERLY Nutrition plays a vital role in the health of older adults, yet one in seven 65-year-olds and over are estimated to be malnourished.3 The importance of good nutrition and hydration in our ageing population can’t be stressed enough. Here, we look at the challenges faced and consider positive interventions for improving nutritional status. The world’s population is ageing. By 2050, a quarter of Europeans are expected to be over the age of 65,1 and this age group already comprises 18% of the UK population.2 Many elderly people are failing to sufficiently meet their nutrient requirements through dietary intake, and an estimated 46% of those in long-term care facilities face current or impending dehydration.4 The need for ensuring adequate nutrition and hydration in the elderly is recognised by the World Health Organisation as an issue of paramount importance,5 particularly since the current COVID-19 pandemic has exacerbated such problems. The UK’s National Diet and Nutrition Survey data reveals that older adults are consuming high amounts of free sugars and saturated fat, whilst daily average fruit and vegetable consumption is below the recommended five a day. Furthermore, this age group often fails to consume adequate amounts of oily fish, total energy, vitamin D, riboflavin, iron, B6 and B12.1,2 Inadequate intakes of various nutrients, coupled with the unique daily challenges that prevail as we age, highlight the need to promote healthy dietary habits among the elderly. THE IMPORTANCE OF NUTRITION AND HYDRATION IN OLDER ADULTS

As we age, we are typically less mobile and muscle and bone mass decrease.

Kelly Fleetwood MSc ANutr

Subsequently, basal metabolic rate decreases. However, maintaining a nutrient-dense diet is still of critical importance. Adequate nutrition can prevent, modulate, or ameliorate many age-related diseases and conditions and, as such, adequate nutritional status can benefit the health and quality of life for older adults.6,7 Malnutrition is associated with longer hospital-stay duration, cognitive impairment, hypotension, infections and mortality, whilst prolonged malnutrition can cause further deterioration of nutritional status due to lack of interest in eating.6,8 Some nutrients are also particularly important for maintaining optimum functioning of the immune system, in which changes occur as we age.1 Furthermore, malnutrition has been associated with depression in older adults; suicide rates are twice as high amongst 80- to 84-year-olds than in the general population.9 Although older adults tend to be more vulnerable to underconsumption in institutional care, obesity is more prevalent in free-living older adults and can contribute to existing health conditions, such as being less mobile, sarcopenia and frailty.1,10 Additionally, dehydration can lead to functional impairment and dizziness and subsequently increased risk of falls,

Kelly is a Registered Associate Nutritionist and Brand Manager in the food industry. Alongside improving the nutritional profile of well-loved food brands, Kelly offers freelance consultancy, with specialist areas in nutrition for vulnerable groups, the gut microbiome and nutrigenomics. www.kellylightnutrition.co.uk kellyinthekitchen kitknutrition

REFERENCES Please visit: nhdmag.com/ references.html

www.NHDmag.com March 2021 - Issue 161

COMMUNITY

The food industry also has a role to play in the nutritional status of older adults; making packaging easier to open and to read . . . for example, can help negate food avoidance. heart attack. Omega-3 may help to alleviate symptoms of rheumatoid arthritis alongside preserving eye health, preventing cognitive decline and improving immune function.13 • Furthermore, magnesium, selenium and calcium might be important nutrients in treating and/or preventing sarcopenia, though more research is needed in this area.14 alongside prolonged hospitalisation stays, pressure sores and constipation.3,11 Nutrition and hydration in older adults, therefore, requires sufficient attention. NUTRIENTS OF PARTICULAR SIGNIFICANCE

Research suggests that some nutrients are of particular significance for older adults: • Protein requirements are a highly debated aspect of nutrition in the elderly and consumption is important for functions such as maintaining muscle mass, wound healing and illness recovery.6 • Vitamin D plays a role in preserving muscle mass, strength and physical function,12 alongside calcium for preserving bone mineral density and fracture prevention.6 • B6, folic acid and B12 all play a role in homocysteine metabolism – elevated homocysteine levels are associated with cardiovascular disease, impaired cognitive function and dementia.6 • Fibre is important for preventing constipation and for providing an overall enhancement of the gut microbiome – bacterial diversity and beneficial bacteria decline as we age, so fibre may offer a novel solution to many aspects of health in the elderly.1,3,9 • Omega-3, due to its anti-inflammatory properties, protects against heart disease and helps those who have already experienced a 42

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CHALLENGES FACING OLDER ADULTS

As we age, we experience many physiological changes that affect the way we perceive, consume and digest food. Firstly, poor vision and changes in taste and smell of food can hamper preprandial food cues and lessen the appeal of food.8 Alongside swallowing difficulties experienced by many older adults, reduced saliva and thus a dry mouth can also occur (known as xerostomia), which can ultimately lead to avoidance of certain foods, particularly those which are hard or sticky.6 Additionally, use of multiple medications can induce nausea and affect appetite, exacerbated by a deregulation of hormones ghrelin, leptin and cholecystokinin, which can often occur in older adults.1,6,15 There can also be a reduction in gastric acid secretion, as well as slower gastrointestinal motor function and food transit, resulting in prolonged postprandial satiety and, hence, reduced food intake.1,6 Furthermore, absorption, storage, distribution and utilisation of certain nutrients can become limited and can be the case for vitamin D, B vitamins, iron and calcium.3,13,15 The ability to stay sufficiently hydrated also becomes more difficult as we age. This is in part due to reduced renal function, which can impair fluid balance, and a reduced thirst sensation, which is more prominent in those with Alzheimer’s disease or stroke.17 Cognitive impairment can mean that some older adults forget to drink, whilst incontinence and the need for toilet assistance can lead to anxiety surrounding drinking.17

COMMUNITY In addition to physiological changes, older adults are more likely to receive a low income and live alone, both of which are associated with compromised food intake.1 The ability to source and cook food also becomes more difficult due to loss of dexterity and strength, further jeopardising the likelihood of adequate nutrient consumption. IMPROVING NUTRITION AND HYDRATION

A multifaceted approach is required in order to improve nutritional and hydration status in older adults. It is particularly important to pay attention to those residing in long-term care, sheltered housing and hospitalised patients. Prevalence of malnutrition and dehydration are believed to be up to 50% higher in such environments due to increased likelihood of cognitive and functional impairment, as well as health conditions that place additional demands on the body and a reliance on others for care.3,15,18 As such, it is recommended that relevant staff are trained to recognise the importance and detection of malnutrition and dehydration in the elderly and work to prevent its occurrence. There is some disagreement surrounding a gold standard measure of malnutrition in hospitalised patients, hence further research in this area would be beneficial;8 however, BMI, haemoglobin and total cholesterol are useful biomarkers.19 Signs of dehydration include dry mouth, lips and tongue, sunken eyes, dry and inelastic skin, drowsiness, confusion, hypotension and concentrated urine.16 To encourage increased food intake, mealtimes should be taken alongside other residents, as research suggests social atmosphere can enhance the enjoyment of food in older adults.6 Positive interventions include the following: • Food should be varied and palatable for older adults who have sensory ailments, and involvement in food preparation where possible may help stimulate appetite.6 • Meal deliveries for those in sheltered housing can alleviate challenges in sourcing and cooking food. • Providing preferred and constant available fluids and assistance with drinking could help ensure older adults are adequately hydrated.16

• Any nutrition education programmes should incorporate a positive, realistic attitude towards food and mealtimes, to help ensure longer-term success.20 • Incorporating elements of physical activity and resistance training may further enhance positive outcomes.10 THE ROLE OF THE FOOD INDUSTRY AND RESEARCH

The food industry also has a role to play in the nutritional status of older adults; making packaging easier to open and to read (by featuring a sizeable font, for example) can help negate food avoidance.6 In terms of diet composition, it is most widely suggested that the Mediterranean diet is most suitable for meeting the nutrition requirements of older adults.4 Supplement products may be of benefit to some older adults when food intake is limited, although this requires support from qualified healthcare professionals and can be expensive.18 More research is needed to identify appropriate elderly-specific requirements of certain nutrients.21 Most macro- and micronutrient recommendations for older adults are currently the same as those for younger adults, despite indications that requirements may change as adults age. For example, vitamin D requirements may be higher in the elderly due to reduced sunlight exposure,6 and protein requirements may be higher than those currently provided. More randomised controlled trials of sufficient quality will be beneficial in improving our understanding of associations between nutrition and health in older adults. CONCLUSION

Nutrition and hydration are important factors in the health and quality of life of older adults. This population group is faced with several physiological and socioeconomic challenges that make malnutrition and dehydration more likely. As such, better awareness, detection and preventative measures are required in settings where such conditions are most prevalent. The food industry might also play a role in making food preparation more accessible to the elderly, and further research on elderly-specific nutrient requirements will be beneficial. www.NHDmag.com March 2021 - Issue 161

DIET & LIFESTYLE

Bessie Brumble RD Bessie is a fulltime Specialist Diabetes Dietitian in the NHS, with an interest and background in mental health. She is currently studying for her postgraduate diploma in Diabetes, which she hopes will lead onto a Masters. bessiedietitan

REFERENCES Please visit: nhdmag.com/ references.html

CHOLESTEROL: THE GOOD, THE BAD . . . OR THE ‘LOUSY’ Working with patients with raised cholesterol levels can be challenging. This article gives an overview of cholesterol and its impact on the body, along with recommendations and dietary interventions for reducing CVD risks. Cholesterol is a type of fat also known as a lipid. The waxy substance plays an important role in the body for the production and structure of cell membranes, steroid hormones, bile acids for fat absorption and vitamin D.1,2 To transport around the body, lipids attach to proteins forming lipoproteins. There are different types of cholesterol, defined by their different structures and actions within the body. Arguably, the most commonly referred to are lowdensity lipoproteins (LDL) and highdensity lipoproteins (HDL). LDL are referred to as the bad or ‘lousy’ cholesterol. They have large lipid molecules, which provide for the actions named above, and deposit excess in the arteries. This depositing then results in the formation of atherosclerotic plaque, commonly termed to patients as the furring up of the arteries, which contributes to cardiovascular diseases (CVDs). On the other hand, high density lipoproteins (HDL) are often referred to as good or healthy cholesterol. They have a much larger protein molecule and a main function to transport cholesterol away from the cells and out of the arteries and to the liver. Here they can be broken down and removed from the body.3 Another type of cholesterol is triglycerides, which will be mentioned later. As we rely on cholesterol for a range of important bodily processes, it should

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come as no surprise that the body is able to produce it. This rather complex process occurs mainly in the liver and intestines. And whilst I’m not going to go into the detail of the pathways, I will tell you that the process is sensitive, easily disrupted by hormones, lifestyle and other physiological variables. A clinical example of cholesterol disruption can be seen in insulin resistance (commonly seen in Type 2 diabetes and polycystic ovarian syndrome), whereby the body’s cholesterol absorption efficiency is low and synthesis high, resulting in abnormal levels.2 High cholesterol (or abnormal lipids) causes a significant impact on public health through increased risk of CVD, a leading cause of death in the UK. Abnormal lipids are commonly asymptomatic, posing the threat that many people can live without awareness or intervention for many years. It is documented that deaths from CVD have hugely declined since the 1980s, but this is thought to be due to advances in medical care.4 In the UK, selective screening in people identified as at risk (based on age, weight and comorbidities such as hypertension or diabetes) is recommended. Table 1 shows cholesterol targets from NHS Choices.5 This is just a guide. The levels aimed for might be different and individuals should ask their doctor or nurse what their levels should be.

DIET & LIFESTYLE Table 1: Target levels for cholesterol5 Result

Healthy level

Total cholesterol

5 or below

HDL (good cholesterol)

1 or above

LDL (bad cholesterol)

3 or below

Non-HDL (bad cholesterol)

4 or below

Triglycerides

2.3 or below

SACN recommendations on saturated fats and health (2019)4 S.24 It is recommended that: • the dietary reference value for saturated fats remains unchanged: the [population] average contribution of saturated fatty acids to [total] dietary energy be reduced to no more than about 10%. This recommendation applies to adults and children aged five years and older. • saturated fats are substituted with unsaturated fats. More evidence is available supporting substitution with PUFA than substitution with MUFA. S.25 This recommendation is made in the context of existing UK Government recommendations for macronutrients and energy. S.26 It is recommended that the Government gives consideration to strategies to reduce the [population] average contribution of saturated fatty acids to [total] dietary energy to no more than about 10%. Risk managers should be mindful of the available evidence in relation to substitution of saturated fats with different types of unsaturated fats and ensure that strategies are consistent with wider dietary recommendations, including trans fats. DIETARY INTERVENTIONS

Dietary cholesterol As mentioned above, the cholesterol producing pathway in the body is sensitive. A common thought is that our cholesterol levels are a direct reflection on the cholesterol that we eat; however, this isn’t quite true. Cholesterol-containing foods such as eggs, shellfish, meat and dairy are understood to only contribute to around 15% of the cholesterol found in a person’s blood.6 It’s thought that on average we consume less than 300mg/day, which Heart UK recommends is the dietary cholesterol limit for people with CVD risk factors. For people with familial hypercholesterolemia (genetic high cholesterol), the recommendation is lowered to 200mg/day. To put it in to perspective: • Chicken, pork and fish are generally lower than 100mg per 100g serving. • One small egg serving is around 185mg. • Prawns are around 210mg per 140g serving. • Offal varies, however liver and kidneys are higher per 100g serving than shellfish.7

Dietary fat Although dietary cholesterol does not have a significant impact on blood cholesterol, dietary fat does. In 2019, the Scientific Advisory Committee on Nutrition (SACN) reviewed the evidence between saturated fats and health outcomes in the general UK population. This backed the historic view that reducing saturated fats reduces the risk of CVD and coronary heart disease events, lowers total cholesterol, LDL and HDL cholesterol and also improves indicators of glycaemic control. SACN recommends saturated fat (SF) is limited to 10% total daily fat intake in people over five years old. All other fats should come firstly from polyunsaturated and secondly monounsaturated sources. SACN also advises government towards public health policies that enable the population to meet the recommendations. See box above. Fibre Strong evidence suggests that increased intakes of total dietary fibre, particularly from grains, are cardioprotective. Oat bran and isolated www.NHDmag.com March 2021 - Issue 161

DIET & LIFESTYLE

Cholesterol-containing foods such as eggs, shellfish, meat and dairy are understood to only contribute to around 15% of the cholesterol found in a person’s blood. β-glucans have been associated with lower total cholesterol, LDL cholesterol, triacylglycerol concentrations and lower blood pressure.8 NHS Choices agrees with the beneficial effect of fibre for cholesterol and overall CVD risk reduction. To achieve the recommended daily intake of 30g, dietary sources to include are: wholemeal bread, bran and wholegrain cereals, fruit and vegetables, potatoes with their skins on, oats and barley, pulses, nuts and seeds.9

Triglycerides (TG) are stored in our body fat and are understood to be very responsive to our lifestyle. A person with high TG, high body fat and low activity levels is likely to find behaviour change to address these areas will result in significant TG reduction. Nutrition considerations also include following fat swap guidance (above), reducing added sugars and moderating alcohol.13

Cholesterol-lowering products Current national guidance does not recommend plant stanols and sterols in the prevention of CVD.10 This is contrary to much evidence in their support. For example, the British Heart Foundation reports that there is evidence to support an 8-12% cholesterol reduction, but that plant stanols and sterols are not recommended in guidance as there isn’t the evidence for reduced risk of heart attack and stroke.11 I often have patients wanting to start these products and after providing the evidence, would advise them to speak with their GP and request for bloods to be monitored.

Cholesterol is more complex than lifestyle behaviours alone. Statins are the most common drug prescribed to lower cholesterol. They are incredibly effective in reducing CVD risk by reducing LDL cholesterol by 30-50%, reducing triglycerides and increasing HDL. Based on their action on the full lipid profile, statins are widely recommended to people at risk of CVD.14 In my experience, it is very common that patients have heard scare stories and feel stigma towards statins. This regularly results in people not accepting the therapy. Helping to remove the stigma and providing education on the physiology of cholesterol can result in increasing acceptance.

EXERCISE AND ACTIVITY

Keeping active is another huge factor in supporting healthy cholesterol levels. Being active increases HDL and reduces LDL.12 The Government recommends a minimum of 150 minutes of moderate intense activity or 75 minutes of intense activity per week for adults. Recommendations for young adults and children differ. 46

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MEDICATION INTERVENTIONS

CONCLUSION

When working with clients with raised cholesterol, it is vital to remember that the reason for management is to reduce CVD. Cholesterol is one element of CVD risk and where dietary intervention isn’t responding, there are successful medications available to add an additional layer of support.

F2F

FACE TO FACE Ursula meets: BELINDA MORTELL Healthcare Development Manager, Danone Nutricia Accountant BDA England Board Member

Belinda and I shared paths for a year on the BDA Communications and Marketing Committee: she chairing with competence; I attending with interest. But that was five years ago. Today we meet phone-to-phone. The world has changed and we have changed, but it is lovely to catch up and hear about Belinda’s unusual dietetic career, which started in accountancy. “I did maths and extra maths at A-level. Careers advice from a teacher matched with my own ambitions to be earning £££s, made this profession an obvious choice,” she said. Belinda chose to study in Edinburgh, which offered fast track certification, and then enjoyed a few accountancy jobs in Stevenage and London. “It was working for Unilever that gave me a taster into the world of food.” Then to Dublin, because Dublin was where her husband got a job. “I had been thinking about there being more to life than financial accounts. I considered possible health careers and discovered the degree in Human Nutrition and Dietetics offered at Trinity College. This was a difficult course with lots of medicine modules, but I was lucky in that two places were reserved for ‘mature’ students. I had to jump several hurdles of several fierce interviews, and was lucky to be offered a place.” Belinda graduated with both a degree and her firstborn. “My final student placement was on a renal ward, which did not match feeling great in the late stages of pregnancy. On

Ursula Arens RD

one occasion I had to leave because of feeling queasy. I will always remember the words of a kind colleague. She said that feeling unwell during pregnancy never required an apology.” Another spousal job move allowed her to enjoy some time in Gibraltar and, in any case, two small children kept her busy. But North Wales was home, and after many years away, Belinda was thrilled to return. In order to work as a dietitian, she had to obtain HCPC registration, which required the submission of forests of paperwork and took nearly a year. The time and complexity of registration was a frustration. Belinda was able to do some basic dietetic support work for Betsi Cadwaladr University Health Board at Wrexham Maelor Hospital, and so was already part of the team when her HCPC registration was granted. The first dietetic job was a steep learning curve. Belinda got some time in lots of different clinical sections and was always very busy. “There never seemed to be enough time to get to the bottom of the daily to-do list,” she said. Having gained promotion to band 6, Belinda then took on two service improvement projects, looking at weight control support and care homes. “It was interesting to get deeper insights into these areas, but I felt frustrated that there was then little opportunity to enact changes, because, of course, it is all linked to the availability of funding.” The role of dietitians in individual counselling

Ursula has a degree in dietetics and currently works as a freelance writer in Nutrition and Dietetics She enjoys the gifts of Aspergers.

Our F2F interviews feature people who influence nutrition policies and practices in the UK.

REFERENCES Please visit: nhdmag.com/ references.html

www.NHDmag.com March 2021 - Issue 161

FOR HEALTHCARE PROFESSIONAL USE ONLY

INSPIRED BY BREAST MILK Breast milk is best for preterm infants and offers an array of benefits.1 However, when breast milk is not available or is in limited supply, a preterm formula that is nutritionally closer to breast milk offers the best alternative.2

Over 60 years of research in preterm nutrition • 90% short-chain galacto-oligosaccharidess (scGOS)

Breast milk has inspired the development of the prebiotic blend scGOS:lcFOS (9:1)

• 10% long-chain fructo-oligosaccharides (lcFOS)

ScGOS/lcFOS (9:1) is an extensively researched prebiotic compound3 30 clinical trials

55 publications

Benefits of scGOS/lcFOS demonstrated in clinical trials in preterm infants

Reduces the prevalence of clinically relevant pathogens5

Results in significantly softer stools and increased stool frequency4

Significantly reduced stool viscosity and accelerates gastrointestinal transit time6

Stimulates growth of bifidobacteria4

May improve enteral tolerance7

Nutriprem 1 and 2 contain prebiotic oligosaccharides to support gut health4–7

Scan the QR code to learn more about the benefits of prebiotics in a preterm formula Healthcare professional helpline 0800 996 1234 @NutriciaHCPUK nutricia.co.uk IMPORTANT NOTICE: Breastfeeding is best. Nutriprem human milk fortifier, nutriprem protein supplement, hydrolysed nutriprem, nutriprem 1 and 2 are foods for special medical purposes for the dietary management of preterm and low birthweight infants. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Hydrolysed nutriprem, nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low birthweight infants. Refer to label for details.

References: 1. Underwood. Pediatr Clin North Am. 2013;60(1):189–207. 2. Agostoni et al. J Pediatr Gastroenterol Nutr. 2010;50(1):85–91. 3. Gibson et al. Nat. Rev. Gastroenterol. 2017;14:491–502. 4. Boehm et al. Arch Dis Child Fetal Neonatal Ed. 2002;86:F178–F181. 5. Knol et al. Acta Paediatr. 2005;94(Suppl 449):31–33. 6. Mihatsch et al. Acta Paediatr. 2006;95:843–848. 7. Modi N et al. Pediatr Res. 2010;68:440–445.

21-005 February 2021

F2F

She is now Healthcare Development Manager for Danone Nutrition, and enjoys the balance of contacts with both researchers and healthcare practitioners, supporting both towards improving nutrition care to those at risk of malnutrition. for those with obesity has been reduced, and there is much greater use of commercial group support organisations. Targeting and effective use of dietetic time validates this decision, but we both feel sad that while population obesity trends continue to boom, dietetic expertise is channelled mainly into complex cases and bariatric surgery procedures. In 2017, Belinda noticed a job advert for an industry post requiring dietetic expertise. There were two augurs of fate supporting her application. It was her 40th birthday and the post was in North Wales. “I was delighted, after several rounds of interviews, to be offered a job with Danone Nutricia.” Going into a sales job supporting specialist nutritional products allowed her to use her dietetic expertise, but perspectives were very different from her previous NHS job. “Of course, I know lots of dietitians in the area. But working in industry means that you have moved to the other side of the table,” said Belinda. After lots of training, Belinda started in the Early Life Nutrition division. She is now Healthcare Development Manager for Danone Nutrition, and enjoys the balance of contacts with both researchers and healthcare practitioners, supporting both towards improving nutrition care to those at risk of malnutrition. Belinda is looking to start a Masters degree in Research, to look into prescription practices

for nutritional products. Current systems balance budget-holder restraints and clinicalpractice judgements, but are there better ways to target nutritional products within funding limits? Should dietitians have greater controls over these products? Belinda has many questions and perhaps after her Masters project, she will be able to promote evidenced answers. Dietitians need to become more confident and assertive, and good practice is about having expertise and sharing this with colleagues. Being an active member of a professional group is one way to do this and Belinda is currently on the England Board of the BDA. “There have been some changes to representation within the BDA, to the current system of a greater diversity of directors, bringing in a wider base of expertise,” she said. Because the England Board represents such a large geographic terrain it is a challenge to pull together cohesive themes. “But the England Board has a great mix of expertise, and I am sure we will produce some good projects to advance the profession.” Belinda has a brisk can-do-ness about her, and she obviously enjoys the financial risks and benefits that industry projects allow. Of course, most dietitians love numeric detail and being highly organised problem-solvers. But Belinda, more so: the accountancy heart still beats loud. www.NHDmag.com March 2021 - Issue 161

SKILLS & LEARNING

RESOURCES AND ADVICE FOR STUDENTS Taking a step back is often the best step forward. Whether individuals are studying Nutrition & Dietetics or are already working, those who are able to take some time to re-evaluate their approach and improve it are often the most productive.

Naomi Oxberry RD 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.

REFERENCES Please visit: nhdmag.com/ references.html

When struggling at university, it is important to try to pinpoint exactly what it is that you are finding hard, in order to be able to find a solution. Perhaps you are struggling with the volume of work needed? Perhaps it is the content? Or maybe it is something unrelated to the degree and you are struggling with the university lifestyle. After asking students what they are most likely to struggle with, here I offer some advice on how to tackle key questions. “I DON’T KNOW HOW TO GO ABOUT LEARNING”

Learning is very individual, but there is some science to it. Research suggests the best way is to actively test yourself, known as active recall. Retrieving information from memory, relative to passively rereading notes, boosts learning.1 It improves retention of information,2 slows forgetting3 and facilitates the

use of information in new situations.4 Although there are lots of ways to learn, active recall has been shown to be the best. When coupled with ‘spaced repetition’, the efficacy of active recall is amplified. Spaced repetition is where one actively recalls the topic in question regularly and over time. Ideally, active recall of a specific subject would be progressively more spaced out. Ali Abdaal has developed a great way to do this.5 He suggests making a spreadsheet and documenting when you go over learning material. He then recommends giving yourself a generic mark for how well you know that section. For example, if you go through your obesity questions and know everything, you can give yourself 5/5. If, however, you didn’t feel like you did as well as you would like, you can score lower (see Table 1). Using a spreadsheet like the one shown in Table 1 means that you can see

Table 1: Example spreadsheet and score card for learning Week starting

Subject

Score

Subject

Score

14.12.2020

Renal Disease

Obesity

Paediatrics

Metabolics

21.12.2020

Paediatrics

Metabolics

Renal Disease

Arthritis

Next Week

Paediatrics

TBA

Metabolics

TBA

Arthritis

TBA

Obesity

TBA

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Subject

Score

Subject

Score

SKILLS & LEARNING

There are lots of companies offering great software programs and apps to help us organise our notes and keep them in one safe place.

where you are improving. By ‘scoring’ yourself, you can see that the more times you go over something, the better your score is. Another benefit of using the spreadsheet is that by scheduling future weeks in, you develop a study plan that allows you to see how you are doing in preparation for any exams. “HOW DO I DEAL WITH SO MUCH INFORMATION? IS THERE SOFTWARE OUT THERE TO MAKE THINGS EASIER?”

Typing notes on a computer is a great alternative to handwriting notes, mainly because it uses fewer physical folders. There are lots of companies offering great software programs and apps to help us organise our notes and keep them in one safe place. Here, we will be naming just a few. Anki Anki is a flashcard software available for desktops and mobile devices. We know active recall is the best way to retain information and this certainly helps with that. You can make your own decks or import decks from other users and use time otherwise wasted on the bus to revise. However, the program does look ugly and this can put users off, especially at the beginning. But it’s only aesthetics and Anki quickly becomes user-friendly. Notion Notion is an online notetaking software. It allows you to organise your notes in your own way, which is really helpful to make specific sections easy to find. You can nest notes within notes,

which is great for learning. Notion also has a ‘toggle’ function that makes testing yourself easy. Furthermore, the user can program ‘templates’ to structure content, or you can pick a template others have developed. Notion is free. The only downside I found is that although you can drop pictures or images in a note, it is difficult to edit them whilst in the software. One Note One Note is another notetaking software with a variety of functions. It’s from Microsoft and is also free to use. However, the user is less able to organise their notes in their own way, but on the flip side, this makes it easier to get your head around. “HOW DO I BEST ACHIEVE A WORK-LIFE BALANCE?”

Nothing is as important as your health and maintaining a good work-life balance is essential. A poor work-life balance impacts mental health, whilst those with a good work-life balance are more efficient, productive and motivated. Here are a few tips: • Everyone has peaks and troughs in their day; be sure to become aware of when these times are for you. Use a time in the day when you might not usually be productive to take a break and do something you enjoy. • Before starting the year or term, write down a list of social or personal commitments that you would like to prioritise over work. For example, this could include ‘To make sure I spend time with my family at Christmas’, www.NHDmag.com March 2021 - Issue 161

COMING IN THE APRIL 2021 ISSUE: • • • • • • • •

Follow-on formula & appropriate use Parenteral nutrition explained Gastric disorders Nutrition in Renal disease Food first & beyond (ONS) Adult food allergies Public health strategies How to make a career in dietetics

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SKILLS & LEARNING

•

or ‘To make sure I make time for a run three times a week’. Putting this list on the wall behind your workspace can remind you of what’s really important when things get busy. Think about how you will fit this into your week. Try to keep to scheduled working hours. If work overruns, write a To-Do list for yourself for the next day and close the door on your working day. Prioritise your time during the day; do the urgent and important tasks first. Next, complete the tasks that are urgent, but not important, followed by important but not urgent. The tasks that are neither important nor urgent, should be completed last. If you are having a break, have a break. Sometimes, when we relax, we can’t help but think about work. This renders the break ineffective. If it is really difficult to fit everything in the day, don’t try to multitask, try to overlap. For example, if you would like to see a friend and also squeeze in some exercise, could you and your friend go to that class together? This is a great way of making space in the diary.

“WHAT EXTRA-CURRICULAR KNOWLEDGE IS IMPORTANT?”

This is a difficult question to give general advice about as it is specific to your goals. If, however, you are unsure of your goals and are happy to utilise your free time dabbling in nutrition, here are my personal favourite books: • Tim Spector is a professor of epidemiology who has produced a couple of insightful books including The Diet Myth and Spoon Fed. These debunk common myths surrounding food and introduce how the role of the commercial food industry influences our eating habits. • Gut: The Inside Story of our Body’s Most Underrated Organ is an easy-to-read book by gastroenterologist, Giulia Enders. In her book, she takes us through the gut system and touches upon common ailments and how to treat them.

Another great way to get your head around nutrition as a study topic, is to try to delve into current debates that come up regularly in our field. This will provide you with an understanding of hot topics and controversies, so that you may be better prepared for working in this area. Examples of current debates within nutrition include: • Is BMI a good reflection of health? Why do we use it? And in what circumstances should we perhaps not use it? • Are calories a good measurement of food? • How does our nutrition and diet impact climate change? • What is the best way to tackle the obesity epidemic? • Food deserts are found in the UK. How might food economics impact upon these and how might these impact individuals? “WHERE CAN I GET ADVICE FOR FIRST-TIME BUDGETING?”

Seventy-one percent of students revealed to the Save The Student Money Survey that they wish they’d had a better financial education before going to university.6 If you are keen to learn how to make your income stretch and meet all your needs, there are some great resources out there, such as: • MoneySavingExpert – a website for people of all ages, offering financial advice ranging from the best credit cards to saving after Christmas. • Save The Student (STS) – the UK’s leading student money website, educating and supporting students in making their money go further whilst at university. Apps are a great way to budget your income and conveniently keep track of your spending. There are lots out there, including Yolt, Cleo, Money Dashboard and Pariti. These apps will have pros and cons, so it is worth researching them to find the one that best suits your needs. Doing a degree and living at university is not easy, especially during a global pandemic. Although there are lots of resources and advice available online, please also consider talking to someone from student support services within your university if you are struggling; they are there to help too. www.NHDmag.com March 2021 - Issue 161

EVENTS & COURSES

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ROYAL MARSDEN VIRTUAL STUDY DAYS 11th March 2021: Managing Supportive Medicines in Patients with Cancer 30th September – 1st October 2021: Swallowing and Communication www.royalmarsden.nhs.uk/studydays

MATTHEW’S FRIENDS KETO COLLEGE 25th, 26th & 27th May 2021: Day 1: Medical MasterClass on Medical Ketogenic Dietary Therapies Days 2 & 3: Dietetic MasterClass Approved for CPD by the BDA. www.mfclinics.com/keto-college/ketocollege-uk-2021

NUTRITION SOCIETY SPRING CONFERENCE 2021 Gut Microbiome and Health 29th to 30th March 2021 www.nutritionsociety.org/events/spring-conference2021-gut-microbiome-and-health BEHAVIOUR CHANGE SKILLS – PART 3 (NEW ONLINE) 29th – 30th March 2021 BCT trainer: Dympna Pearson and Dr Jackie Doyle www.ncore.org.uk

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RECIPE ANALYSIS: MAXIMISING ACCURACY On behalf of Nutrition and Wellbeing, Susan Church 23rd April 2021 – London (Virtual version also available) Endorsed for CPD by the Association for Nutrition and the BDA www.susanchurchnutrition.co.uk/recipe-analysistraining

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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

Read the NHD Blog: www.nhdmag.com/nhdblog

LOSING TASTE AND SMELL WITH COVID-19 I had COVID over the New Year period. It was something I never expected to get, even though it was rife in the community at the time. I’m sure I picked it up at my local gym. After waking with a temperature and headache, a positive lateral flow test confirmed my fears, which was further confirmed by a PCR test a day later. I suffered with a temperature, headache, achiness, fatigue and a very mild cough. Thankfully, I fully recovered in just 10 days. The strangest symptom for me, however, was losing my smell and taste. It was bizarre to experience loss of those senses without a blockedup nose. I was lucky though, as both returned within about two weeks. My husband is yet to have his senses back to normal after a month. My smell and taste started to go on around day five. It was subtle to begin with. My tea started to taste strange and whilst I was trying to recover by eating healthily again, I naturally chose more fruit; but all fruit suddenly tasted terrible. Apples were bitter and oranges were even worse! In my dietetic practice, I used to work in Oncology and Haematology and so have advised people who are struggling with taste changes due to chemotherapy. As with many things, you never fully realise what something is like until you experience it yourself. The advice I used to give to patients came back to me. You have to find the foods you can tolerate and that taste ok, no matter what. You need to eat something to help with recovery. So, I did just that. The problem was the only hint of taste I was getting was either salty or sweet. My cravings for crisps, chocolate spread and biscuits increased! I tried to eat my evening meals, but unless they were salty or

My cravings for crisps, chocolate spread and biscuits increased!

spicy, I couldn’t really taste anything. I realised my usual healthy options of fruit, nuts and plain yoghurt were off the menu, as I simply couldn’t tolerate them. It was almost like being pregnant again! I simply didn’t want healthy food, yet I knew I needed to eat what was palatable, to provide adequate calories and nutrition. I made sure I was having a banana daily as I could tolerate the sweetness. I chose more salty options for lunch, like bacon, eggs, beans and a bagel – plenty of protein – and I enjoyed it. I loved chocolate spread on toast too. As the days passed, hints of my taste slowly started to return. It was strange, as vegetables were probably one of the first things I could taste again and I could start having salads again too. Losing my taste in particular made me realise the real challenges of finding something you can eat. Combine this with nausea and poor appetite, eating can be really tricky, and I can see how easy it could be to lose a lot of weight quickly without intervention. I know this experience will help me with my dietetic practice and although I am thankful it didn’t last long, I’m almost grateful to have experienced it.

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

www.NHDmag.com March 2021 - Issue 161

ROAR INTO ACTION WITH OUR NEW FORTINI CHOCOLATE-CARAMEL

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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.

Nutritionally complete for children 1+ years of age (>8kg). 300kcal per 125ml bottle and low volume to help aid compliance. Available in 3 flavours.

Network Health Digest March 2021

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